Provider Demographics
NPI:1720187966
Name:LACKAWANNA AMBULANCE, INC
Entity Type:Organization
Organization Name:LACKAWANNA AMBULANCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:BUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-207-5200
Mailing Address - Street 1:1000 REMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-1118
Mailing Address - Country:US
Mailing Address - Phone:570-207-5200
Mailing Address - Fax:570-207-5266
Practice Address - Street 1:1000 REMINGTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-1118
Practice Address - Country:US
Practice Address - Phone:570-207-5200
Practice Address - Fax:570-207-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04164341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0077296000OtherINDEPENDENCE BC ID
NY02635725Medicaid
PA35511OtherHEALTH PARTNERS ID
PA080017000OtherFEDERAL BLACK LUNG ID
PA206068OtherFEDERAL BCBS ID
MD4076133 00Medicaid
PA998575OtherBLUE CROSS NEPA
PA359796600OtherOWCP ID
PA807228OtherFIRST PRIORITY
PA1007506200003Medicaid
PA000000096978OtherTHREE RIVERS HLTH PLN
PA1539617OtherGATEWAY
PA359796600OtherOWCP ID
PA35511OtherHEALTH PARTNERS ID