Healthcare Provider Details
I. General information
NPI: 1720187966
Provider Name (Legal Business Name): LACKAWANNA AMBULANCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 09/22/2006
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1000 REMINGTON AVE
SCRANTON PA
18505-1118
US
IV. Provider business mailing address
1000 REMINGTON AVE
SCRANTON PA
18505-1118
US
V. Phone/Fax
- Phone: 570-207-5200
- Fax: 570-207-5266
- Phone: 570-207-5200
- Fax: 570-207-5266
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 341600000X |
| Taxonomy | Ambulance |
| License Number | 04164 |
| License Number State | PA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 0077296000 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | INDEPENDENCE BC ID |
| # 2 | |
| Identifier | 02635725 |
| Identifier Type | MEDICAID |
| Identifier State | NY |
| Identifier Issuer | |
| # 3 | |
| Identifier | 35511 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | HEALTH PARTNERS ID |
| # 4 | |
| Identifier | 080017000 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FEDERAL BLACK LUNG ID |
| # 5 | |
| Identifier | 206068 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FEDERAL BCBS ID |
| # 6 | |
| Identifier | 4076133 00 |
| Identifier Type | MEDICAID |
| Identifier State | MD |
| Identifier Issuer | |
| # 7 | |
| Identifier | 998575 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | BLUE CROSS NEPA |
| # 8 | |
| Identifier | 359796600 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | OWCP ID |
| # 9 | |
| Identifier | 807228 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FIRST PRIORITY |
| # 10 | |
| Identifier | 1007506200003 |
| Identifier Type | MEDICAID |
| Identifier State | PA |
| Identifier Issuer | |
| # 11 | |
| Identifier | 000000096978 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | THREE RIVERS HLTH PLN |
| # 12 | |
| Identifier | 1539617 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | GATEWAY |
VIII. Authorized Official
Name: MR.
RICHARD
SEAN
BUCKMAN
Title or Position: PRESIDENT CEO
Credential:
Phone: 570-207-5200
