1801300058 NPI number — MEDSOURCE, LLC

Table of content: (NPI 1801300058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801300058 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:
1801300058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2021
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:
888-510-5100
Provider Business Mailing Address Fax Number:
888-510-5200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 PRINTERS PKWY STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80910-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-375-3299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2017

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  20176001145 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20176001145 . This is a "DURABLE MEDICAL EQUIPMENT SUPPLIER LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".