Provider Demographics
NPI:1013072255
Name:KENNESAW MEDICAL SUPPLIES INC
Entity Type:Organization
Organization Name:KENNESAW MEDICAL SUPPLIES INC
Other - Org Name:MECHANICAL EQUIPMENT AIDS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELOTSERKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-422-3978
Mailing Address - Street 1:3055 N MAIN ST NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2787
Mailing Address - Country:US
Mailing Address - Phone:770-422-3978
Mailing Address - Fax:770-422-2612
Practice Address - Street 1:3055 N MAIN ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2787
Practice Address - Country:US
Practice Address - Phone:770-422-3978
Practice Address - Fax:770-422-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4779040001Medicare NSC