Basic Information
| Provider Information | |||||||||
| NPI: | 1417138413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRICOUNTY MEDICAL EQUIPEMENT & SUPPLY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194645427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107059292 | ||||||||
| FaxNumber: | 6107059777 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194645427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107059292 | ||||||||
| FaxNumber: | 6107059777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | GVODAS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6107059292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BX2000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 102053991 0001 | 05 | PA | MEDICAID | 30048227 | 01 | PA | KEYSTONE MERCY | OTHER | 0002789000 | 01 | PA | INDEPENDANCE BLUE CROSS | OTHER |