MEDICARE: PREMIUM CARE MEDICAL TRANSPORT LLC

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	13009	PA

General Provider Information

NPI Number	:	1629416078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM CARE MEDICAL TRANSPORT LLC

Provider Business Mailing Address
First Line	:	8600 W CHESTER PIKE
Second Line	:	SUITE 306
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2629
Country	:	US
Telephone Number	:	610-446-1339
Fax Number	:	215-600-1228

Provider Business Practice Location Address
First Line	:	8600 W CHESTER PIKE
Second Line	:	SUITE 306
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2629
Country	:	US
Telephone Number	:	610-446-1339
Fax Number	:	215-600-1228

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SAMUEL CHARLES
Credential	:
Telephone Number	:	267-227-9133

Provider Enumeration Date	:	06/07/2013
Last Update Date	:	06/07/2013

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