Provider Demographics
NPI:1124092879
Name:PERRY PORT & SALEM AMBULANCE SERVICE INC
Entity type:Organization
Organization Name:PERRY PORT & SALEM AMBULANCE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-538-1802
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:45360-0102
Mailing Address - Country:US
Mailing Address - Phone:937-538-1802
Mailing Address - Fax:
Practice Address - Street 1:205 WALL ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:45360
Practice Address - Country:US
Practice Address - Phone:937-538-1802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02035000210714341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000249684OtherBC/BS
OH2355366Medicaid
OH=========OtherCOMMERCIAL
OH=========OtherCOMMERCIAL