Healthcare Provider Details

I. General information

NPI: 1356546808
Provider Name (Legal Business Name): ADA-LIBERTY JT AMBULANCE DIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NORTH GILBERT STREET
ADA OH
45810
US

IV. Provider business mailing address

10361 SPARTAN DR
CINCINNATI OH
45215-1220
US

V. Phone/Fax

Practice location:
  • Phone: 419-634-7729
  • Fax: 419-634-5290
Mailing address:
  • Phone: 800-962-1484
  • Fax: 513-772-4464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number020304150
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0265672
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier590175429
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier000000156090
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerANTHEM BCBS

VIII. Authorized Official

Name: NANCY D BUCHER
Title or Position: FISCAL OFFICER
Credential:
Phone: 419-634-7729