Provider Demographics
NPI:1992821920
Name:PROVOST, JOHN MARSHALL (CPED)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARSHALL
Last Name:PROVOST
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
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Mailing Address - Street 1:732 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:W HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-3615
Mailing Address - Country:US
Mailing Address - Phone:570-455-7704
Mailing Address - Fax:570-454-6324
Practice Address - Street 1:25 LAUREL MALL
Practice Address - Street 2:PROVOST SHOES
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1201
Practice Address - Country:US
Practice Address - Phone:570-455-7704
Practice Address - Fax:570-455-7704
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PA4244780002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA08009797OtherMEDICARE EDI BILLING NUMB