Provider Demographics
NPI:1508030743
Name:MEDSOURCE MEDICAL DME LLC
Entity Type:Organization
Organization Name:MEDSOURCE MEDICAL DME LLC
Other - Org Name:MEDSOURCE MEDICAL DME LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:DINGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-906-5020
Mailing Address - Street 1:2831 TRICOM ST STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-906-5020
Mailing Address - Fax:843-297-4154
Practice Address - Street 1:320 MIDLAND PKWY
Practice Address - Street 2:STE B
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-7197
Practice Address - Country:US
Practice Address - Phone:843-906-5020
Practice Address - Fax:843-970-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2428Medicaid