Provider Demographics
NPI:1942205943
Name:KENTUCKY MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:KENTUCKY MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-206-0040
Mailing Address - Street 1:3325 BARTLETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-6428
Mailing Address - Country:US
Mailing Address - Phone:407-206-0040
Mailing Address - Fax:407-206-0010
Practice Address - Street 1:102 CASTLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129
Practice Address - Country:US
Practice Address - Phone:270-432-0957
Practice Address - Fax:270-432-0957
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEROCARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2080P0006X
KY177855332B00000X
KY175293332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45907789OtherEPSDT PROVIDER ID NO.
KY7542OtherCHA PROVIDER ID NO.
KY90100058Medicaid
KY000000070314OtherBC PROVIDER ID NO.
KY7542OtherCHA PROVIDER ID NO.