Provider Demographics
NPI:1619164308
Name:ADVANCED MEDICAL INC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-776-4318
Mailing Address - Street 1:PO BOX 7532
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25356-0532
Mailing Address - Country:US
Mailing Address - Phone:304-776-2002
Mailing Address - Fax:304-776-2004
Practice Address - Street 1:128 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1435
Practice Address - Country:US
Practice Address - Phone:304-776-2002
Practice Address - Fax:304-776-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9226145OtherAETNA
WV6012750001Medicare NSC