Provider Demographics
NPI:1720062987
Name:MEMORIAL AMBULANCE CORPS. ISLE AU HAUT - STONINGTON - DEER ISLE
Entity type:Organization
Organization Name:MEMORIAL AMBULANCE CORPS. ISLE AU HAUT - STONINGTON - DEER ISLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR - MEMORIAL AMBULANCE CORPS
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:T
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-I
Authorized Official - Phone:207-348-5686
Mailing Address - Street 1:P O BOX 387
Mailing Address - Street 2:
Mailing Address - City:DEER ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04627
Mailing Address - Country:US
Mailing Address - Phone:207-348-5686
Mailing Address - Fax:207-348-5692
Practice Address - Street 1:77 SUNSHINE RD
Practice Address - Street 2:
Practice Address - City:DEER ISLE
Practice Address - State:ME
Practice Address - Zip Code:04627
Practice Address - Country:US
Practice Address - Phone:207-348-5686
Practice Address - Fax:207-348-5692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME460341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104070000Medicaid
ME701831Medicare ID - Type UnspecifiedPROVIDER NUMBER