Provider Demographics
NPI:1598744435
Name:CANONSBURG GENERAL HOSPITAL AMBULANCE SERVICE
Entity Type:Organization
Organization Name:CANONSBURG GENERAL HOSPITAL AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILTROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-873-5880
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-0207
Mailing Address - Country:US
Mailing Address - Phone:484-664-2007
Mailing Address - Fax:
Practice Address - Street 1:209 W PIKE ST
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-1143
Practice Address - Country:US
Practice Address - Phone:724-745-6911
Practice Address - Fax:724-745-8919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA040053416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
1502794OtherGATEWAY HLTH PLAN HMO DPA
PA241796OtherBCBS OF PA BLUE SHIELD
103520OtherUPMC HEALTH PLAM COMM
590012280OtherUNITED HC RR MEDICARE
1004559OtherAETNA USHC BLUE BELL HMO
PA0016844380002Medicaid
1529544OtherUMWA HEALTH RETIREMENT
1529544OtherUMWA HEALTH RETIREMENT