Provider Demographics
NPI:1972829745
Name:SOUTH MEDICAL SUPPLY
Entity Type:Organization
Organization Name:SOUTH MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:ORTHOTICS FITTER
Authorized Official - Phone:469-667-7483
Mailing Address - Street 1:500 W UNIVERSITY DR
Mailing Address - Street 2:109
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-4823
Mailing Address - Country:US
Mailing Address - Phone:469-667-7483
Mailing Address - Fax:214-377-9999
Practice Address - Street 1:500 W UNIVERSITY DR
Practice Address - Street 2:109
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-4823
Practice Address - Country:US
Practice Address - Phone:469-667-7483
Practice Address - Fax:214-377-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000339332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000000Medicare UPIN
TX0000000000Medicare NSC