Provider Demographics
NPI:1679660245
Name:PHYSICAL MEDICINE DEVICES LLC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE DEVICES LLC
Other - Org Name:JEFFERY A SHEAHAN DBA PHYSICAL MEDICINE DEVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-860-6650
Mailing Address - Street 1:1356 COUNTRY SQUIRE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2202
Mailing Address - Country:US
Mailing Address - Phone:866-860-6650
Mailing Address - Fax:800-995-2763
Practice Address - Street 1:203 AMICKS FERRY RD
Practice Address - Street 2:STE 700
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8696
Practice Address - Country:US
Practice Address - Phone:866-860-6650
Practice Address - Fax:800-995-2763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC040678855332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2009Medicaid
SC5861250001Medicare NSC