Healthcare Provider Details

I. General information

NPI: 1629049598
Provider Name (Legal Business Name): MONONGAHELA MEDICAL SUPPLY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 COUNTRY CLUB RD MPOB SUITE 104
MONONGAHELA PA
15063-1013
US

IV. Provider business mailing address

1163 COUNTRY CLUB RD MPOB SUITE 104
MONONGAHELA PA
15063-1013
US

V. Phone/Fax

Practice location:
  • Phone: 724-258-2273
  • Fax: 724-258-6111
Mailing address:
  • Phone: 724-258-2273
  • Fax: 724-258-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number601899
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001014628003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier601899
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerDOH DEVICE DEALER

VIII. Authorized Official

Name: MR. EDWARD JOSEPH ROSENSTEEL
Title or Position: DME MANAGER
Credential:
Phone: 412-258-1318