Provider Demographics
NPI:1699774018
Name:LIFESTAR RESPONSE OF MARYLAND, INC
Entity type:Organization
Organization Name:LIFESTAR RESPONSE OF MARYLAND, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-464-4888
Mailing Address - Street 1:PO BOX 827284
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7284
Mailing Address - Country:US
Mailing Address - Phone:410-247-1178
Mailing Address - Fax:410-536-5476
Practice Address - Street 1:10840 GUILFORD RD STE 404
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS JUNCTION
Practice Address - State:MD
Practice Address - Zip Code:20701-1110
Practice Address - Country:US
Practice Address - Phone:410-247-1178
Practice Address - Fax:410-536-5476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FALCK USA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-18
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD743416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055000100Medicaid
DC018652100Medicaid
DC018652100Medicaid
MD055000100Medicaid