1083750210 NPI number — SUPERIOR MEDICAL SUPPLY INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083750210 NPI number — SUPERIOR MEDICAL SUPPLY INC

Employer Identification Number (EIN):

Provider Organization Name:

SUPERIOR MEDICAL SUPPLY INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

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Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

Provider Other Organization Name Type Code:

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Provider Other Last Name Type Code:

NPI Number:

1083750210

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

08/17/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6025 LEE HIGHWAY

Provider Second Line Business Mailing Address:

SUITE 431

Provider Business Mailing Address City Name:

CHATTANOOGA

Provider Business Mailing Address State Name:

TN

Provider Business Mailing Address Postal Code:

37421

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

931-551-9333

Provider Business Mailing Address Fax Number:

931-551-8435

Provider First Line Business Practice Location Address:

1160 GALLATIN PIKE S STE 109

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MADISON

Provider Business Practice Location Address State Name:

TN

Provider Business Practice Location Address Postal Code:

37115

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

615-865-3239

Provider Business Practice Location Address Fax Number:

931-551-8435

Provider Enumeration Date:

01/29/2007

Authorized Official Last Name:

CARTER

Authorized Official First Name:

THOMAS

Authorized Official Middle Name:

BRYAN

Authorized Official Title or Position:

COO

Authorized Official Telephone Number:

855-230-5632

• Taxonomy code: 332B00000X , with the licence number:  0000000615 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 90274275 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 01359837 . This is a "AMERIGROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 1455279 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 24521 . This is a "CARECENTRIX" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 2444181000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: TN0101 . This is a "AMERICHOICE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 2377653 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 4195118 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 1954093 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 50002684 . This is a "PASSPORT HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".