Provider Demographics
NPI:1538298542
Name:ILLINOIS DURABLE MEDICAL EQUIPMENT & SUPPLY, INC.
Entity Type:Organization
Organization Name:ILLINOIS DURABLE MEDICAL EQUIPMENT & SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALERY
Authorized Official - Middle Name:
Authorized Official - Last Name:DVORKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-548-8688
Mailing Address - Street 1:1099 N CORPORATE CIR
Mailing Address - Street 2:UNIT H & I
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1688
Mailing Address - Country:US
Mailing Address - Phone:847-548-8688
Mailing Address - Fax:847-548-8686
Practice Address - Street 1:1099 N CORPORATE CIR
Practice Address - Street 2:UNIT H & I
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1688
Practice Address - Country:US
Practice Address - Phone:847-548-8688
Practice Address - Fax:847-548-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid