Provider Demographics
NPI:1134137730
Name:MG MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:MG MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:AXEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-743-2453
Mailing Address - Street 1:2962 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5101
Mailing Address - Country:US
Mailing Address - Phone:718-743-2453
Mailing Address - Fax:718-743-2352
Practice Address - Street 1:2962 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5101
Practice Address - Country:US
Practice Address - Phone:718-743-2453
Practice Address - Fax:718-743-2352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0898352332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01369066Medicaid
NY01369066Medicaid