Provider Demographics
NPI:1336245083
Name:TICONDEROGA EMERGENCY SQUAD INC
Entity Type:Organization
Organization Name:TICONDEROGA EMERGENCY SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL LT.
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-503-5055
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-0265
Mailing Address - Country:US
Mailing Address - Phone:518-503-5055
Mailing Address - Fax:518-391-2601
Practice Address - Street 1:118 CHAMPLAIN AVENUE
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883
Practice Address - Country:US
Practice Address - Phone:518-503-5055
Practice Address - Fax:518-391-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10140341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
9602724OtherGHI
NY01629978Medicaid
700010OtherMVP
NY54833BMedicare ID - Type Unspecified