Provider Demographics
NPI:1205852860
Name:BRAINERD MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:BRAINERD MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEWEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-2100
Mailing Address - Street 1:206 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2922
Mailing Address - Country:US
Mailing Address - Phone:218-829-2100
Mailing Address - Fax:218-829-8943
Practice Address - Street 1:206 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2922
Practice Address - Country:US
Practice Address - Phone:218-829-2100
Practice Address - Fax:218-829-8943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4598796332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8214066OtherMEDICA
MN81238BROtherBLUE CROSS BLUE SHIELD
MN120979OtherUCARE
MN120979OtherUCARE