MEDICARE: GOSPEL AMBULANCE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance

General Provider Information

NPI Number	:	1164790168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOSPEL AMBULANCE, INC.

Provider Business Mailing Address
First Line	:	2179 BENNETT RD
Second Line	:	UNIT A
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3021
Country	:	US
Telephone Number	:	908-420-4110
Fax Number	:	215-464-5666

Provider Business Practice Location Address
First Line	:	2179 BENNETT RD
Second Line	:	UNIT A
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3021
Country	:	US
Telephone Number	:	908-420-4110
Fax Number	:	215-464-5666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. IVAN GERTSEN
Credential	:
Telephone Number	:	908-420-4110

Provider Enumeration Date	:	12/05/2011
Last Update Date	:	12/05/2011

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