Provost Shoes

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

License

4244780002 Issued in PA

Legal business name

PROVOST SHOES

Practice address

25 Laurel Mall
Hazleton, PA 18202-1201

Phone

(570) 455-7704

Fax

(570) 455-7704

NPI assigned

Nov 26, 2007

Last updated

Dec 5, 2007By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John M Provost, C. PEDNPI 1992821920

Title

Owner

Phone

(570) 455-7704

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in PA

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• John Marshall Provost, C.PED

  • Durable Medical Equipment & Medical Supplies
  • Hazleton, PA
  • NPI 1992821920
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196035200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1196812800000",
    "number": "1447431945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25 LAUREL MALL",
            "city": "HAZLETON",
            "state": "PA",
            "postal_code": "182021201",
            "telephone_number": "570-455-7704",
            "fax_number": "570-455-7704"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25 LAUREL MALL",
            "city": "HAZLETON",
            "state": "PA",
            "postal_code": "182021201",
            "telephone_number": "570-455-7704",
            "fax_number": "570-455-7704"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVOST SHOES",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-26",
        "last_updated": "2007-12-05",
        "status": "A",
        "authorized_official_last_name": "PROVOST",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "570-455-7704",
        "authorized_official_credential": "C. PED"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "PA",
            "license": "4244780002",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE EDI BILLING NUMB",
            "identifier": "A08009797",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Poole Chiropractic Inc.
• Isaac Michael Porter, PA-C
• Portonova Chiropractic, LLC
• Michael John Portonova, D.C.
• Leocadia T Prawdzik, MD
• John Marshall Provost, C.PED
• George Puhak, DMD
• Janine Pusti, MD
• Syed F Qadri, MD
• George J Racho, MD

• Durable Medical Equipment & Medical Supplies in Hazleton, PA
• Providers in Hazleton, PA by specialty
• Durable Medical Equipment & Medical Supplies in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.