MEDICARE: PREMIER OHIO TRANSPORTATION IN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1598308298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER OHIO TRANSPORTATION IN

Provider Business Mailing Address
First Line	:	17325 EUCLID AVE STE 3029
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1255
Country	:	US
Telephone Number	:	216-410-4751
Fax Number	:

Provider Business Practice Location Address
First Line	:	17325 EUCLID AVE STE 3029
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1255
Country	:	US
Telephone Number	:	216-410-4751
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DELONTE FOMBY
Credential	:
Telephone Number	:	216-410-4751

Provider Enumeration Date	:	10/25/2019
Last Update Date	:	10/25/2019

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