Provider Demographics
NPI:1891795829
Name:BROOKESIDE AMBULANCE SERVICE INC
Entity Type:Organization
Organization Name:BROOKESIDE AMBULANCE SERVICE INC
Other - Org Name:RUMPF AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-476-7442
Mailing Address - Street 1:640 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612
Mailing Address - Country:US
Mailing Address - Phone:419-476-7442
Mailing Address - Fax:419-476-9936
Practice Address - Street 1:640 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612
Practice Address - Country:US
Practice Address - Phone:419-476-7442
Practice Address - Fax:419-476-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH480022341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0816399Medicaid
OH9241871Medicare ID - Type Unspecified