Provider Demographics
NPI:1225150493
Name:MTN CITY PROSTHTICS & ORTHOTICS
Entity Type:Organization
Organization Name:MTN CITY PROSTHTICS & ORTHOTICS
Other - Org Name:RUSSELL STEADELE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STEADELE
Authorized Official - Suffix:I
Authorized Official - Credentials:CPO
Authorized Official - Phone:570-455-7486
Mailing Address - Street 1:1053 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-1447
Mailing Address - Country:US
Mailing Address - Phone:570-455-7486
Mailing Address - Fax:
Practice Address - Street 1:1053 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1447
Practice Address - Country:US
Practice Address - Phone:570-455-7486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA215659OtherPA BLUE SHIELD
PA39HA67OtherCAPITAL BLUE CROSS
PA0018417720002Medicaid
PA28295OtherDEMENSION BENEFITS PLAN
PA814373OtherFIRST PRIORITY HEALTH
PA215659OtherPA BLUE SHIELD
PA0188070001Medicare PIN
PA39HA67OtherCAPITAL BLUE CROSS