Provider Demographics
NPI:1942389127
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 1:650 N GIRLS SCHOOL RD STE C35
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-3660
Practice Address - Country:US
Practice Address - Phone:317-863-3760
Practice Address - Fax:317-863-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2021-01-15
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
INLICENSEOther69000622A
INLICENSEOther69000622A