Provider Demographics
NPI:1720033913
Name:JESSA MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:JESSA MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MUSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-990-8706
Mailing Address - Street 1:235 KENTLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-5446
Mailing Address - Country:US
Mailing Address - Phone:301-990-8706
Mailing Address - Fax:240-631-7113
Practice Address - Street 1:235 KENTLANDS BLVD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5446
Practice Address - Country:US
Practice Address - Phone:301-990-8706
Practice Address - Fax:240-631-7113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR1058332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD363570800Medicaid
VA009109668Medicaid