Provider Demographics
NPI:1932187655
Name:SPORTOPEDICS MEDICAL SHOPPE INC.
Entity Type:Organization
Organization Name:SPORTOPEDICS MEDICAL SHOPPE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-475-7210
Mailing Address - Street 1:1222 S PATTERSON BLVD
Mailing Address - Street 2:SUITE #130
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2684
Mailing Address - Country:US
Mailing Address - Phone:937-461-2663
Mailing Address - Fax:937-461-3448
Practice Address - Street 1:1222 S PATTERSON BLVD
Practice Address - Street 2:SUITE #130
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2684
Practice Address - Country:US
Practice Address - Phone:937-461-2663
Practice Address - Fax:937-461-3448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301408Medicaid
OH0301408Medicaid
OH1107490001Medicare NSC