Provider Demographics
NPI:1164417366
Name:MEDSOURCE INC.
Entity Type:Organization
Organization Name:MEDSOURCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-771-3939
Mailing Address - Street 1:10520 S 700 E STE 210
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-0943
Mailing Address - Country:US
Mailing Address - Phone:801-771-3939
Mailing Address - Fax:888-506-2344
Practice Address - Street 1:10520 S 700 E STE 210
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-0943
Practice Address - Country:US
Practice Address - Phone:801-771-3939
Practice Address - Fax:888-828-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0827150001Medicare NSC