Provider Demographics
NPI:1518920859
Name:SALEM MEDICAL RESOURCES & SUPPLIES LLC
Entity Type:Organization
Organization Name:SALEM MEDICAL RESOURCES & SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHISTS
Authorized Official - Phone:517-896-9882
Mailing Address - Street 1:5927 BUTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9758
Mailing Address - Country:US
Mailing Address - Phone:517-896-9882
Mailing Address - Fax:516-339-5297
Practice Address - Street 1:1380 HASLETT RD
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-9779
Practice Address - Country:US
Practice Address - Phone:517-896-9882
Practice Address - Fax:517-339-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-08
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINOT APPLICABLE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5285890001Medicare NSC