Provider Demographics
NPI:1962478800
Name:VILLAGE OF MEDINA
Entity Type:Organization
Organization Name:VILLAGE OF MEDINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-798-1661
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-0186
Mailing Address - Country:US
Mailing Address - Phone:585-768-2192
Mailing Address - Fax:585-768-7323
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1577
Practice Address - Country:US
Practice Address - Phone:585-768-2192
Practice Address - Fax:585-768-7323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36153416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01367179Medicaid
NY01367179Medicaid