Provider Demographics
NPI:1477612364
Name:JESSUP HOSE CO 2
Entity Type:Organization
Organization Name:JESSUP HOSE CO 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAMELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-489-1141
Mailing Address - Street 1:PO BOX 1846
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-0846
Mailing Address - Country:US
Mailing Address - Phone:570-714-3694
Mailing Address - Fax:
Practice Address - Street 1:333 HILL ST
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:PA
Practice Address - Zip Code:18434-1036
Practice Address - Country:US
Practice Address - Phone:570-498-1141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA051173416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
800356OtherFEDERAL BLACK LUNG
PA0011760450001Medicaid
PA286993Medicare ID - Type Unspecified