Provider Demographics
NPI:1376642116
Name:E & S MEDICAL SUPPLY CO
Entity Type:Organization
Organization Name:E & S MEDICAL SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEFOREST
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SHOBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-395-1026
Mailing Address - Street 1:500 BROADWAY
Mailing Address - Street 2:STE B
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2393
Mailing Address - Country:US
Mailing Address - Phone:219-395-1026
Mailing Address - Fax:219-395-1625
Practice Address - Street 1:500 BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2393
Practice Address - Country:US
Practice Address - Phone:219-395-1026
Practice Address - Fax:219-395-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0007209908332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200211710AMedicaid
IN200211710AMedicaid