Provider Demographics
NPI:1184711822
Name:EVERGREEN SURGICAL SUPPLY INC.
Entity type:Organization
Organization Name:EVERGREEN SURGICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHI
Authorized Official - Middle Name:HONG
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-439-6038
Mailing Address - Street 1:5703 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3807
Mailing Address - Country:US
Mailing Address - Phone:718-439-6038
Mailing Address - Fax:718-439-6045
Practice Address - Street 1:5703 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3807
Practice Address - Country:US
Practice Address - Phone:718-439-6038
Practice Address - Fax:718-439-6045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1127183332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01717591Medicaid
NY01717591Medicaid