Provider Demographics
NPI:1720133986
Name:WIDENERS AMBULANCE SERVICE, INC
Entity Type:Organization
Organization Name:WIDENERS AMBULANCE SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-862-4339
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:NORTHFORK
Mailing Address - State:WV
Mailing Address - Zip Code:24868-0728
Mailing Address - Country:US
Mailing Address - Phone:304-862-4339
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTHFORK
Practice Address - State:WV
Practice Address - Zip Code:24868
Practice Address - Country:US
Practice Address - Phone:304-862-4339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNO NUMBER3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0144749000Medicaid
WV9234071Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER