Healthcare Provider Details

I. General information

NPI: 1114773660
Provider Name (Legal Business Name): HEADWATERS EMERGENCY MEDICAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 TERRY RD
STAMFORD NY
12167-1940
US

IV. Provider business mailing address

PO BOX 535
BALDWINSVILLE NY
13027-0535
US

V. Phone/Fax

Practice location:
  • Phone: 607-434-1666
  • Fax: 607-214-6958
Mailing address:
  • Phone: 800-927-5845
  • Fax: 315-635-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND BAKER JR.
Title or Position: DIRECTOR
Credential:
Phone: 607-434-1666