=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114919081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLK JACKSON PERRY VOLUNTEER FIREFIGHTERS & SQUADPERSONS ASSICI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2005
-----------------------------------------------------
Last Update Date | 05/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 E CONGRESS ST
-----------------------------------------------------
City | POLK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44866-9701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-945-2681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 392907
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15251-9907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-962-1484
-----------------------------------------------------
Fax | 513-772-4464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FISCAL OFFICER
-----------------------------------------------------
Name | KATHLEEN WILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-945-2681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 020363050
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------