Basic Information
| Provider Information | |||||||||
| NPI: | 1780643148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENFIELD AREA LIFE SQUAD INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 640 NORTH WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379813394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | MAYNARD | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9379813394 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0270120 | 05 | OH | MEDICAID | 000000000345 | 01 | ANTHEM BCBS | OTHER |