Provider Demographics
NPI:1407030448
Name:AKRON PRINCEVILLE AMBULANCE INC
Entity Type:Organization
Organization Name:AKRON PRINCEVILLE AMBULANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-682-5280
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:319 E MAIN STREET
Mailing Address - City:PRINCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61559-0021
Mailing Address - Country:US
Mailing Address - Phone:309-682-5280
Mailing Address - Fax:309-682-5327
Practice Address - Street 1:319 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:PRINCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61559-0021
Practice Address - Country:US
Practice Address - Phone:309-682-5280
Practice Address - Fax:309-682-5327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000026113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07232089OtherBLUE CROSS BLUE SHIELD
590004694OtherPALMETTO GBA
IL=========001Medicaid
662640Medicare PIN