Provider Demographics
NPI:1780023705
Name:MIDDLEBURGH EMERGENCY VOLUNTEER AMBULANCE CORPS INC
Entity Type:Organization
Organization Name:MIDDLEBURGH EMERGENCY VOLUNTEER AMBULANCE CORPS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-257-7080
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:860-257-7080
Mailing Address - Fax:860-563-3403
Practice Address - Street 1:142 COTTON HILL ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURGH
Practice Address - State:NY
Practice Address - Zip Code:12122-9998
Practice Address - Country:US
Practice Address - Phone:518-827-8098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4717341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03828911Medicaid
NY03828911Medicaid