Provider Demographics
NPI:1245276112
Name:MIDSTATE MEDICAL SERVICE
Entity type:Organization
Organization Name:MIDSTATE MEDICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-263-6034
Mailing Address - Street 1:PO BOX 6070
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-0070
Mailing Address - Country:US
Mailing Address - Phone:334-263-6034
Mailing Address - Fax:334-264-2436
Practice Address - Street 1:1507 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1519
Practice Address - Country:US
Practice Address - Phone:334-263-6034
Practice Address - Fax:334-264-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0003497332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000051822Medicaid
ALU98718OtherAMERIHEALTH PROV. NUM.
AL304307OtherCOMBINED INS. CO. OF AMER
TN4582366Medicaid
AL51051822MIDOtherBCBS PROVIDER NUMBER
AL0007965237OtherAETNA PROVIDER NUMBER
ALV16192OtherVGM/HOMELINK PROV. NUM.
AL304307OtherHEALTH INS. CORP. OF ALA.
AL=========OtherTRICARE PROVIDER NUMBER
AL=========OtherVIVA MEDICARE PLUS
AL=========OtherVIVA HEALTH, INC.