Provider Demographics
NPI:1336137884
Name:ELLICOTTVILLE GREAT VALLEY AMBULANCE INC
Entity Type:Organization
Organization Name:ELLICOTTVILLE GREAT VALLEY AMBULANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-699-2300
Mailing Address - Street 1:555 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5723
Mailing Address - Country:US
Mailing Address - Phone:716-204-3350
Mailing Address - Fax:
Practice Address - Street 1:FILMORE AVE
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731-0074
Practice Address - Country:US
Practice Address - Phone:716-945-1398
Practice Address - Fax:716-945-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04273416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02653703Medicaid
NY02653703Medicaid