Healthcare Provider Details

I. General information

NPI: 1235346552
Provider Name (Legal Business Name): OLD FORGE AMBULANCE & RESCUE ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 RAILROAD ST
OLD FORGE PA
18518-2003
US

IV. Provider business mailing address

PO BOX 207
ALLENTOWN PA
18105-0207
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-9693
  • Fax: 570-504-8343
Mailing address:
  • Phone: 484-664-2007
  • Fax: 484-664-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number05134
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier590007073
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier0012373830004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier801316
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFEDERAL BLACK LUNG

VIII. Authorized Official

Name: ROBERT GOTAY
Title or Position: TREASURER
Credential:
Phone: 570-457-9693