=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700814878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGENCY TRANSPORT ASSOCIATES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 09/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S 11TH ST SUITE 2130
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8500-51695
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19178-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, CLINICAL / SUPPORT
-----------------------------------------------------
Name | MR. BRIAN SWEENEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-955-7937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 04295
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------