Provider Demographics
NPI:1922264159
Name:MEDSOURCE LLC
Entity Type:Organization
Organization Name:MEDSOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-664-7930
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-1248
Mailing Address - Country:US
Mailing Address - Phone:309-664-7930
Mailing Address - Fax:309-664-7931
Practice Address - Street 1:2301 W 1ST ST
Practice Address - Street 2:STE 5
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-2470
Practice Address - Country:US
Practice Address - Phone:515-965-6967
Practice Address - Fax:515-965-6973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000461332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0598110Medicaid
IA4448650005Medicare NSC