Provider Demographics
NPI:1073835039
Name:NORTHEAST MEDICAL SALES
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL SALES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANNECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-965-0964
Mailing Address - Street 1:315 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18844-8019
Mailing Address - Country:US
Mailing Address - Phone:570-965-0964
Mailing Address - Fax:570-965-0964
Practice Address - Street 1:2354 OLD POST RD
Practice Address - Street 2:SUITE 2
Practice Address - City:COPLAY
Practice Address - State:PA
Practice Address - Zip Code:18037-2461
Practice Address - Country:US
Practice Address - Phone:610-262-3331
Practice Address - Fax:610-262-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PA6000004877332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39HA79OtherCAPITAL BLUE CROSS
PA0016073300002Medicaid
PA1517547OtherGATEWAY/GATEWAY MEDICARE ASSURED
PA0016073300002Medicaid