Provider Demographics
NPI:1821395229
Name:EXPRESS CARE MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:EXPRESS CARE MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYASOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-451-0073
Mailing Address - Street 1:12 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2100
Mailing Address - Country:US
Mailing Address - Phone:248-451-0073
Mailing Address - Fax:
Practice Address - Street 1:12 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2100
Practice Address - Country:US
Practice Address - Phone:248-451-0073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6612000001OtherMEDICARE PTAN