Provider Demographics
NPI:1336151315
Name:BROOKE COUNTY COMMISSION
Entity Type:Organization
Organization Name:BROOKE COUNTY COMMISSION
Other - Org Name:BROOKE COUNTY AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:K. ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-737-7094
Mailing Address - Street 1:836 4TH AVE
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 1:54 MARSHALL STREET
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070
Practice Address - Country:US
Practice Address - Phone:304-737-7094
Practice Address - Fax:304-737-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWVEMS3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand TransportGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVAMB302OtherUPPER OHIO VALLEY H PLAN
WV0145167000Medicaid
OHAMB302OtherUPPER OHIO VALLEY H PLAN
WV001705606OtherMT STATE BLUE CROSS