Provider Demographics
NPI:1053987446
Name:ALS MOUNT VERNON INC
Entity type:Organization
Organization Name:ALS MOUNT VERNON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGYANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-620-7828
Mailing Address - Street 1:26261 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COOLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45723-9204
Mailing Address - Country:US
Mailing Address - Phone:740-350-9095
Mailing Address - Fax:
Practice Address - Street 1:1135 GAMBIER RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3839
Practice Address - Country:US
Practice Address - Phone:740-415-1138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2630NOtherLICENSURE
OH0234954Medicaid