Provider Demographics
NPI:1679859169
Name:MEDSOURCE MEDICAL, LLC
Entity Type:Organization
Organization Name:MEDSOURCE MEDICAL, LLC
Other - Org Name:INGRAM MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-577-7767
Mailing Address - Street 1:9883 S 500 W
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2561
Mailing Address - Country:US
Mailing Address - Phone:877-577-7767
Mailing Address - Fax:801-727-0092
Practice Address - Street 1:9883 S 500 W
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2561
Practice Address - Country:US
Practice Address - Phone:877-577-7767
Practice Address - Fax:801-727-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8119067-1714332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4612138OtherNCPDP PROVIDER IDENTIFICATION NUMBER