Provider Demographics
NPI:1235212556
Name:PROFESSIONAL MEDICAL & SURGICAL SUPPLY, INC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL & SURGICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:FERRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:815-726-6279
Mailing Address - Street 1:1917 GARNET CT
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1593
Mailing Address - Country:US
Mailing Address - Phone:800-648-5190
Mailing Address - Fax:866-656-6332
Practice Address - Street 1:1917 GARNET CT
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1593
Practice Address - Country:US
Practice Address - Phone:800-648-5190
Practice Address - Fax:866-656-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3143388Medicaid
WI41742200Medicaid
MI5306003914OtherWHOLESALER LICENSE
IN69000595AOtherHME LICENSE
MNNPI FOR MHCPMedicaid
PA102562380Medicaid
GA146633158AMedicaid
MOF01075656OtherCERTIFICATE OF AUTHORITY
AL1043OtherHME
KS16-00483OtherDME
KS200714550AMedicaid
IL203.001039OtherHME LICENSE
IL203.001039OtherHME
IN69000595AOtherHME
NE100259906-00Medicaid
OH1347042OtherSTATE OF OHIO FOREIGN BUSINESS LICENSE
PA6000007643OtherCERTIFICATE OF DEVICE REGISTRATION
KY7100081800Medicaid
IA1235212556Medicaid
GA1235212556Medicaid
WI013081177Medicaid
NY03333653Medicaid
MS08574/11.1OtherMEDICAL EQUIPMENT SUPPLIER
MO1235212556 FOR MOMedicaid
KYHME00240OtherHME
OHHME22862OtherHME
TN104409276OtherCERTIFICATE OF REGISTRATION SALE & USE
IN200819870AMedicaid
NY3XXXX3409 FOR NYOtherCERTIFICATE OF AUTHORITY
MIME-0156417Medicaid
IANPIMedicaid
UT1235212556 FOR UTMedicaid
ARMG01323OtherSUPPLIER OF MEDICAL EQUIPMENT LICENSE
IA1235212556Medicaid
IL0241430001Medicare NSC