Provider Demographics
NPI:1861462244
Name:T.D. MEDICAL LLC
Entity Type:Organization
Organization Name:T.D. MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-252-8211
Mailing Address - Street 1:9495 WINNETKA AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1618
Mailing Address - Country:US
Mailing Address - Phone:629-252-8211
Mailing Address - Fax:763-255-3972
Practice Address - Street 1:12323 SW 55TH ST STE 1004
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33330-3312
Practice Address - Country:US
Practice Address - Phone:954-921-9099
Practice Address - Fax:954-921-1937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FL596332BC3200X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL672210596Medicaid
FL209238700Medicaid
FL209238779Medicaid
FL0155760001Medicare NSC