Provider Demographics
NPI:1932223369
Name:CHARLESTOWN VOLUNTEER FIRE DEPT
Entity Type:Organization
Organization Name:CHARLESTOWN VOLUNTEER FIRE DEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-256-6202
Mailing Address - Street 1:PO BOX 2915
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2915
Mailing Address - Country:US
Mailing Address - Phone:574-293-3030
Mailing Address - Fax:
Practice Address - Street 1:800 PARK ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-1657
Practice Address - Country:US
Practice Address - Phone:812-256-6202
Practice Address - Fax:812-256-2094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10153416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200508500AMedicaid
IN000000368554OtherANTHEM
IN200508500AMedicaid
IN226020Medicare ID - Type UnspecifiedMEDICARE