Provider Demographics
NPI:1316255003
Name:ETHRIDGE GROUP INC
Entity type:Organization
Organization Name:ETHRIDGE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-257-7080
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:860-257-7080
Mailing Address - Fax:860-563-3403
Practice Address - Street 1:10301 NORTHWEST FWY STE 205
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8225
Practice Address - Country:US
Practice Address - Phone:281-445-7616
Practice Address - Fax:713-957-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101502341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285396201Medicaid
TXAMB1110Medicare PIN