Provider Demographics
NPI:1548271752
Name:CONVERSE AMBULANCE CORPORATION
Entity type:Organization
Organization Name:CONVERSE AMBULANCE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-395-1157
Mailing Address - Street 1:PO BOX 2915
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2915
Mailing Address - Country:US
Mailing Address - Phone:574-293-3030
Mailing Address - Fax:574-294-1345
Practice Address - Street 1:210 N. JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:IN
Practice Address - Zip Code:46919
Practice Address - Country:US
Practice Address - Phone:765-395-3459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200454280AMedicaid
IN000000250990OtherANTHEM
P00399943OtherRRMC PTAN
IN200454280AMedicaid
IN000000250990OtherANTHEM