Provider Demographics
NPI:1588662662
Name:EXPRESS CARE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:EXPRESS CARE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:I
Authorized Official - Last Name:ILYASOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-968-2999
Mailing Address - Street 1:25900 GREENFIELD RD
Mailing Address - Street 2:# 121
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1292
Mailing Address - Country:US
Mailing Address - Phone:248-968-2999
Mailing Address - Fax:248-968-9699
Practice Address - Street 1:25900 GREENFIELD RD
Practice Address - Street 2:# 121
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1292
Practice Address - Country:US
Practice Address - Phone:248-968-2999
Practice Address - Fax:248-968-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI874585890Medicaid
MI145043OtherPPOM
MI540F322010OtherBCBS
MI540F322010OtherBCBS