Provider Demographics
NPI:1417114984
Name:MEDICALSUPPLY LLC
Entity Type:Organization
Organization Name:MEDICALSUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-302-6337
Mailing Address - Street 1:8023 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4507
Mailing Address - Country:US
Mailing Address - Phone:414-302-6337
Mailing Address - Fax:
Practice Address - Street 1:8023 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4507
Practice Address - Country:US
Practice Address - Phone:414-302-6337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41569900Medicaid
WI6044810001Medicare NSC