Provider Demographics
NPI:1073523163
Name:SPARTAN MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:SPARTAN MEDICAL SUPPLIES LLC
Other - Org Name:SPARTAN MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRASSL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-668-6066
Mailing Address - Street 1:8849 PINE ISLAND COURT SOUTH
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9570
Mailing Address - Country:US
Mailing Address - Phone:269-668-6066
Mailing Address - Fax:269-924-0675
Practice Address - Street 1:8849 PINE ISLAND COURT SOUTH
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9570
Practice Address - Country:US
Practice Address - Phone:269-668-6066
Practice Address - Fax:269-924-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4747470Medicaid
MI5404010180OtherBLUE CROSS BLUE SHIELD
MI5404010180OtherBLUE CROSS BLUE SHIELD