Provider Demographics
NPI:1790093466
Name:MEDSOURCE MIDWEST, LLC
Entity Type:Organization
Organization Name:MEDSOURCE MIDWEST, LLC
Other - Org Name:WAGENSELLER & COMPANY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGENSELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-334-3773
Mailing Address - Street 1:6315 FM 1488 RD STE B
Mailing Address - Street 2:BOX 244
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-2526
Mailing Address - Country:US
Mailing Address - Phone:832-334-3773
Mailing Address - Fax:
Practice Address - Street 1:71 S ALMONDELL CIR
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-3373
Practice Address - Country:US
Practice Address - Phone:832-334-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies