Provider Demographics
NPI:1982923397
Name:PORT JEFFERSON VOLUNTEER AMBULANCE INC
Entity Type:Organization
Organization Name:PORT JEFFERSON VOLUNTEER AMBULANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF TRAINING
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZERUS
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-CC
Authorized Official - Phone:631-473-2519
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-0264
Mailing Address - Country:US
Mailing Address - Phone:631-473-2519
Mailing Address - Fax:631-476-6716
Practice Address - Street 1:25 CRYSTAL BROOK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-1612
Practice Address - Country:US
Practice Address - Phone:631-473-2519
Practice Address - Fax:631-476-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12194146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Multi-Specialty