Provider Demographics
NPI:1417233545
Name:EXPRESS MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:EXPRESS MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKPARVARFARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-441-4267
Mailing Address - Street 1:2615 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801
Mailing Address - Country:US
Mailing Address - Phone:814-308-8155
Mailing Address - Fax:
Practice Address - Street 1:2615 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801
Practice Address - Country:US
Practice Address - Phone:814-308-8155
Practice Address - Fax:814-308-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424252332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010805460001Medicaid
083991Medicare Oscar/Certification