=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699064121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QRST2 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 E FRONT ST
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-924-4795
-----------------------------------------------------
Fax | 610-565-5474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 E FRONT ST
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-924-4795
-----------------------------------------------------
Fax | 610-565-5474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | EUGENE GITTELMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-924-4795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 99999
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------