Provider Demographics
NPI:1770501736
Name:MEDISOURCE HOME MEDICAL
Entity Type:Organization
Organization Name:MEDISOURCE HOME MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:770-528-9559
Mailing Address - Street 1:975 COBB PLACE BLVD NW STE 113
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6848
Mailing Address - Country:US
Mailing Address - Phone:770-528-9559
Mailing Address - Fax:770-528-9309
Practice Address - Street 1:975 COBB PLACE BLVD NW STE 113
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6848
Practice Address - Country:US
Practice Address - Phone:770-528-9559
Practice Address - Fax:770-528-9309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52164995OtherBCBS
GA341310291AMedicaid
GA1023735OtherUHC
GA1023735OtherUHC