1154643112 NPI number — MED SOURCE SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154643112 NPI number — MED SOURCE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED SOURCE SERVICES INC
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:
1154643112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24901 NORTHWESTERN HWY
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-2203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-357-2100
Provider Business Mailing Address Fax Number:
248-357-2380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24901 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-2203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-357-2100
Provider Business Practice Location Address Fax Number:
248-357-4272
Provider Enumeration Date:
02/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DIXON
Authorized Official First Name:
CLARENCE
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-746-0882

Provider Taxonomy Codes

  • Taxonomy code: 202C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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