=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205863453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN SHORE AMBULANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 08/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 AIRLINE BLVD
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23701-2661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-343-7153
-----------------------------------------------------
Fax | 757-787-9436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 538194
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30353-8194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-343-7153
-----------------------------------------------------
Fax | 757-787-9436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AR MANAGER
-----------------------------------------------------
Name | MR. MATTHEW THOMAS ELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 866-343-7153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 535
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------