Provider Demographics
NPI:1922032275
Name:MEDISOURCE CORP
Entity Type:Organization
Organization Name:MEDISOURCE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARBEITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:VP
Authorized Official - Phone:561-361-9604
Mailing Address - Street 1:7040 W PALMETTO PARK RD
Mailing Address - Street 2:#4-575
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3407
Mailing Address - Country:US
Mailing Address - Phone:561-361-9604
Mailing Address - Fax:561-394-5186
Practice Address - Street 1:7025 BERACASA WAY
Practice Address - Street 2:SUITE 102B
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3443
Practice Address - Country:US
Practice Address - Phone:561-361-9604
Practice Address - Fax:561-394-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1065190001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1065190001Medicare NSC