Healthcare Provider Details

I. General information

NPI: 1992821920
Provider Name (Legal Business Name): JOHN MARSHALL PROVOST C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LAUREL MALL PROVOST SHOES
HAZLETON PA
18202-1201
US

IV. Provider business mailing address

732 NORTH ST
W HAZLETON PA
18202-3615
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-7704
  • Fax: 570-455-7704
Mailing address:
  • Phone: 570-455-7704
  • Fax: 570-454-6324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4244780002
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA08009797
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE EDI BILLING NUMB

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: