Provider Demographics
NPI:1588676233
Name:ACTIVA MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:ACTIVA MEDICAL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMEKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-266-6160
Mailing Address - Street 1:1901 N MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5219
Mailing Address - Country:US
Mailing Address - Phone:312-266-6160
Mailing Address - Fax:
Practice Address - Street 1:2212 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-8467
Practice Address - Country:US
Practice Address - Phone:312-266-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000704332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5461260001Medicare NSC