Provider Demographics
NPI:1417066424
Name:BURKESVILLE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:BURKESVILLE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-864-2230
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-0006
Mailing Address - Country:US
Mailing Address - Phone:270-864-2230
Mailing Address - Fax:270-864-2691
Practice Address - Street 1:365 KEEN ST
Practice Address - Street 2:
Practice Address - City:BURKESVILLE
Practice Address - State:KY
Practice Address - Zip Code:42717-0006
Practice Address - Country:US
Practice Address - Phone:270-864-2230
Practice Address - Fax:270-864-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X
KYMG0187332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000070347OtherANTHEM BC/BS
KY006895400OtherBLACK LUNG
KY7100164320Medicaid
KY90040296Medicaid
KY45906005OtherESPDT
KY7100165970OtherESDPT
KY90040296Medicaid