1821088964 NPI number — KOFFEL MEDICAL SUPPLY INC

Table of content: (NPI 1821088964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821088964 NPI number — KOFFEL MEDICAL SUPPLY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOFFEL MEDICAL 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:
1821088964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 W PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-2550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 W PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-2550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-816-8000
Provider Business Practice Location Address Fax Number:
847-816-8606
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KOFFEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-816-8000

Provider Taxonomy Codes

  • Taxonomy code: 332BD1200X , 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: 59379 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0701390 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90002692 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0440301 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0944694 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0877243 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4581798 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00673978X , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3742601 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1531235 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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