Provider Demographics
NPI:1669456190
Name:NORTHEAST HARBOR AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:NORTHEAST HARBOR AMBULANCE SERVICE, INC.
Other - Org Name:NORTHEAST HARBOR AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:207-276-5256
Mailing Address - Street 1:P O BOX 122
Mailing Address - Street 2:
Mailing Address - City:NORTHEAST HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04662
Mailing Address - Country:US
Mailing Address - Phone:207-276-5288
Mailing Address - Fax:207-276-5288
Practice Address - Street 1:21 SEA STREET
Practice Address - Street 2:
Practice Address - City:NORTHEAST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04662
Practice Address - Country:US
Practice Address - Phone:207-276-5288
Practice Address - Fax:207-276-5288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME4903416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME168200000Medicaid
ME=========OtherTAX ID NUMBER
ME168200000Medicaid