Provider Demographics
NPI:1023053717
Name:LIFE STAR MEDICAL SUPPLIES
Entity type:Organization
Organization Name:LIFE STAR MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-267-6020
Mailing Address - Street 1:2308 POETS LN
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2308 POETS LN
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6650
Practice Address - Country:US
Practice Address - Phone:708-267-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5723810002Medicare NSC