=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437347945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMON COURTESY TRANSPORTATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 ALVIN AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-288-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 ALVIN AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-288-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FREDERICK MATHIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-288-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 187415
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------