MEDICARE: LAKE GEORGE POST NO. 374 AMERICAN LEGION EMERGENCY SQUAD 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	341600000X	Ambulance	10256	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	9602726	OTHER	GHI
2	960242	OTHER	MVP
3	000400571001	OTHER	BS OF NENY
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	10027217	OTHER	CDPHP

General Provider Information

NPI Number	:	1215999669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE GEORGE POST NO. 374 AMERICAN LEGION EMERGENCY SQUAD INC.

Provider Business Mailing Address
First Line	:	107 WASHINGTON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12210-2269
Country	:	US
Telephone Number	:	518-668-9506
Fax Number	:	518-668-5898

Provider Business Practice Location Address
First Line	:	24 GAGE RD
Second Line	:
City	:	LAKE GEORGE
State	:	NY
Zip	:	12845-6130
Country	:	US
Telephone Number	:	518-668-9506
Fax Number	:	518-668-5898

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRUCE W KILBURN
Credential	:
Telephone Number	:	518-668-9506

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	06/29/2015

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