=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366440638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSTAR AMBULANCE SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23208 MAIN ST
-----------------------------------------------------
City | COURTLAND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23837-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-653-2873
-----------------------------------------------------
Fax | 757-653-2453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23208 MAIN ST
-----------------------------------------------------
City | COURTLAND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23837-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-653-2873
-----------------------------------------------------
Fax | 757-653-2453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT-MANAGER
-----------------------------------------------------
Name | PAMELA PHELPS MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-653-2873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 792
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------