=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174892343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMESTAR AMBULANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2011
-----------------------------------------------------
Last Update Date | 12/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2337 PHILMONT AVE SUITE 99
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-947-7100
-----------------------------------------------------
Fax | 215-947-7101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 114
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-0114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-947-7100
-----------------------------------------------------
Fax | 215-947-7101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS ISHEEMAH BURTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-947-7100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 11055
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------