Provider Demographics
NPI:1407888175
Name:STAR MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:STAR MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAYAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-276-3100
Mailing Address - Street 1:3502 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4123
Mailing Address - Country:US
Mailing Address - Phone:410-276-3100
Mailing Address - Fax:410-843-3000
Practice Address - Street 1:3502 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4123
Practice Address - Country:US
Practice Address - Phone:410-276-3100
Practice Address - Fax:410-843-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402967400Medicaid
MD4788600001Medicare ID - Type Unspecified