Provider Demographics
NPI:1093059792
Name:MEDSTATE INC.
Entity Type:Organization
Organization Name:MEDSTATE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRENEO
Authorized Official - Middle Name:
Authorized Official - Last Name:ONGCAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-962-0688
Mailing Address - Street 1:496 S BEACON LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-5408
Mailing Address - Country:US
Mailing Address - Phone:847-740-2774
Mailing Address - Fax:847-201-2578
Practice Address - Street 1:496 S BEACON LN
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-5408
Practice Address - Country:US
Practice Address - Phone:847-740-2774
Practice Address - Fax:847-201-2578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL68750911332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies