=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003053745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE MEDICAL TRANSPORTATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2009
-----------------------------------------------------
Last Update Date | 01/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1985 BYBERRY RD UNIT A-1
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-956-0303
-----------------------------------------------------
Fax | 215-956-0302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1985 BYBERRY RD UNIT A-1
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-956-0303
-----------------------------------------------------
Fax | 215-956-0302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ANDREI BORISSOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-659-0303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 08024
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------