1922264159 NPI number — MEDSOURCE LLC

Table of content: (NPI 1922264159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922264159 NPI number — MEDSOURCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSOURCE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922264159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61702-1248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-664-7930
Provider Business Mailing Address Fax Number:
309-664-7931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 W 1ST ST
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
ANKENY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50023-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-965-6967
Provider Business Practice Location Address Fax Number:
515-965-6973
Provider Enumeration Date:
08/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROHDE
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-664-7930

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  203.000461 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0598110 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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