Provider Demographics
NPI:1205928843
Name:OXYCARE MEDICAL SUPPLY COMPANY
Entity type:Organization
Organization Name:OXYCARE MEDICAL SUPPLY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WIMMERSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-234-0202
Mailing Address - Street 1:2725 S BELT W
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-6777
Mailing Address - Country:US
Mailing Address - Phone:618-234-0202
Mailing Address - Fax:618-234-2209
Practice Address - Street 1:2725 S BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-6777
Practice Address - Country:US
Practice Address - Phone:618-234-0202
Practice Address - Fax:618-234-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000429332BP3500X, 332BX2000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232154OtherBLUE CROSS BLUE SHIELD
IL08232154OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid