Provider Demographics
NPI:1962538900
Name:COMMUNITY AMBULANCE SERVICE CLUB
Entity type:Organization
Organization Name:COMMUNITY AMBULANCE SERVICE CLUB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-943-8013
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:TOWER CITY
Mailing Address - State:PA
Mailing Address - Zip Code:17980-0033
Mailing Address - Country:US
Mailing Address - Phone:717-647-2271
Mailing Address - Fax:
Practice Address - Street 1:633 EAST COLLIERY AVENUE
Practice Address - Street 2:
Practice Address - City:TOWER CITY
Practice Address - State:PA
Practice Address - Zip Code:17980
Practice Address - Country:US
Practice Address - Phone:717-943-8013
Practice Address - Fax:717-647-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA041413416L0300X
PA01135341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA590007322OtherRR MEDICARE
PA0012143980004Medicaid
PA50004678OtherCAPITAL BLUE CROSS
PA0130130OtherTHREE RIVERS
PA50004678OtherKEYSTONE SENIOR BLUE
PA893120OtherBLACK LUNG PROGRAM
PA20018661OtherAMERIHEALTH MERCY
PA20018661OtherAMERIHEALTH MERCY