Provider Demographics
NPI:1720200991
Name:PETERSTOWN VOLUNTEER FIRE DEPARTMENT AND RESCUE SQUAD INC
Entity Type:Organization
Organization Name:PETERSTOWN VOLUNTEER FIRE DEPARTMENT AND RESCUE SQUAD INC
Other - Org Name:PETERSTOWN VOLUNTEER FIRE AND RESCUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-521-1576
Mailing Address - Street 1:836 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1407
Mailing Address - Country:US
Mailing Address - Phone:304-521-1576
Mailing Address - Fax:304-521-1768
Practice Address - Street 1:218 MARKET STREET
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963
Practice Address - Country:US
Practice Address - Phone:304-753-4343
Practice Address - Fax:304-753-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
WVWVEMS341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001705363OtherBC/BS
WV0145724000Medicaid
WV001705363OtherMT. STATE BLUE CROSS
WV9173601Medicare PIN