Provider Demographics
NPI:1851454664
Name:MEDICAL SERVICE AND SUPPORT LLC MBFS
Entity Type:Organization
Organization Name:MEDICAL SERVICE AND SUPPORT LLC MBFS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RENGARAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:GANESAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:773-746-6050
Mailing Address - Street 1:500 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1659
Mailing Address - Country:US
Mailing Address - Phone:773-746-6050
Mailing Address - Fax:
Practice Address - Street 1:500 LINDEN AVENUE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1659
Practice Address - Country:US
Practice Address - Phone:773-746-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01883194251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage