=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720062987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL AMBULANCE CORPS. ISLE AU HAUT - STONINGTON - DEER ISLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2005
-----------------------------------------------------
Last Update Date | 11/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 SUNSHINE RD
-----------------------------------------------------
City | DEER ISLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-348-5686
-----------------------------------------------------
Fax | 207-348-5692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 387
-----------------------------------------------------
City | DEER ISLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-348-5686
-----------------------------------------------------
Fax | 207-348-5692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR - MEMORIAL AMBULANCE CORPS
-----------------------------------------------------
Name | WALTER T. REED
-----------------------------------------------------
Credential | EMT-I
-----------------------------------------------------
Telephone | 207-348-5686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 460
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 460
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------