Provider Demographics
NPI:1760519391
Name:COMMUNITY DURABLE MEDICAL EQUIPMENT
Entity Type:Organization
Organization Name:COMMUNITY DURABLE MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-331-9812
Mailing Address - Street 1:3057 WINCHESTER AVE.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136
Mailing Address - Country:US
Mailing Address - Phone:215-331-9812
Mailing Address - Fax:215-331-9816
Practice Address - Street 1:4706 BLAKISTON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-1515
Practice Address - Country:US
Practice Address - Phone:215-331-9812
Practice Address - Fax:215-331-9816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000004713332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0002764000OtherBLUE CROSS
PA0014580451Medicaid
PA0015804510003Medicaid
PA0014580451Medicaid