Provider Demographics
NPI:1235339243
Name:MOUNT NITTANY MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNT NITTANY MEDICAL CENTER
Other - Org Name:MOUNT NITTANY MEDICAL CENTER ORTHOTICS SUPPLIER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-234-6148
Mailing Address - Street 1:1800 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 RADNOR RD
Practice Address - Street 2:MNMC - ORTHOTICS
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7970
Practice Address - Country:US
Practice Address - Phone:814-231-7125
Practice Address - Fax:814-238-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100746655 0020Medicaid
5999040001Medicare NSC
PA100746655 0020Medicaid