Provider Demographics
NPI:1639155823
Name:WF BRUEN EMERGENCY SQUAD INC
Entity Type:Organization
Organization Name:WF BRUEN EMERGENCY SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFF CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-424-0248
Mailing Address - Street 1:1116 RED MILL RD
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-5503
Mailing Address - Country:US
Mailing Address - Phone:518-477-8243
Mailing Address - Fax:
Practice Address - Street 1:1116 RED MILL RD
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-5503
Practice Address - Country:US
Practice Address - Phone:518-477-8243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104553416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000900405000OtherBLUE SHIELD
NY02338810Medicaid
NY281000003OtherMVP
NY281000003OtherMVP
NYDD4336Medicare ID - Type Unspecified