Provider Demographics
NPI:1467599373
Name:ADVANCED MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-663-8881
Mailing Address - Street 1:PO BOX 6705
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-0705
Mailing Address - Country:US
Mailing Address - Phone:608-663-8881
Mailing Address - Fax:888-299-5568
Practice Address - Street 1:4411 GORDON AVE STE 1
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-1013
Practice Address - Country:US
Practice Address - Phone:608-663-8881
Practice Address - Fax:888-299-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41731100Medicaid
WI41731100Medicaid
IL=========001Medicaid
IL=========001Medicaid