Provider Demographics
NPI:1366653545
Name:ONE SOURCE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ONE SOURCE MEDICAL GROUP LLC
Other - Org Name:ONE SOURCE MEDICAL GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-834-7473
Mailing Address - Street 1:13910 LYNMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3123
Mailing Address - Country:US
Mailing Address - Phone:866-834-7473
Mailing Address - Fax:877-490-9111
Practice Address - Street 1:13910 LYNMAR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626
Practice Address - Country:US
Practice Address - Phone:813-792-3560
Practice Address - Fax:877-490-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-27
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1313496332B00000X
332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032072200Medicaid
5703548OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5953470001Medicare NSC