Provider Demographics
NPI:1487906632
Name:PROSTAT, INC.
Entity type:Organization
Organization Name:PROSTAT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:SHELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-225-7090
Mailing Address - Street 1:395 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-2145
Mailing Address - Country:US
Mailing Address - Phone:570-225-7090
Mailing Address - Fax:570-225-7097
Practice Address - Street 1:1901 BERNVILLE RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601-1113
Practice Address - Country:US
Practice Address - Phone:610-736-9000
Practice Address - Fax:610-736-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA23393601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024232050002Medicaid
PA1024232050001Medicaid
PA1024232050003Medicaid