1235212556 NPI number — PROFESSIONAL MEDICAL & SURGICAL SUPPLY, INC

Table of content: (NPI 1235212556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235212556 NPI number — PROFESSIONAL MEDICAL & SURGICAL SUPPLY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL MEDICAL & SURGICAL SUPPLY, 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:
1235212556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1917 GARNET CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451-1593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-648-5190
Provider Business Mailing Address Fax Number:
866-656-6332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1917 GARNET CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-1593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-648-5190
Provider Business Practice Location Address Fax Number:
866-656-6332
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERRY
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
815-726-6279

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3143388 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41742200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5306003914 . This is a "WHOLESALER LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 69000595A . This is a "HME LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: NPI FOR MHCP , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102562380 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146633158A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: F01075656 . This is a "CERTIFICATE OF AUTHORITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1043 . This is a "HME" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 16-00483 . This is a "DME" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200714550A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203.001039 . This is a "HME LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 203.001039 . This is a "HME" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 69000595A . This is a "HME" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100259906-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1347042 . This is a "STATE OF OHIO FOREIGN BUSINESS LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 6000007643 . This is a "CERTIFICATE OF DEVICE REGISTRATION" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7100081800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235212556 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235212556 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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