Provider Demographics
NPI:1255494787
Name:STAR MEDICAL EQUIPMENT, LLC
Entity type:Organization
Organization Name:STAR MEDICAL EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-386-9220
Mailing Address - Street 1:1161 E KIMBERLY RD
Mailing Address - Street 2:STE. A
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1769
Mailing Address - Country:US
Mailing Address - Phone:563-386-9220
Mailing Address - Fax:
Practice Address - Street 1:1161 E KIMBERLY RD
Practice Address - Street 2:STE. A
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1769
Practice Address - Country:US
Practice Address - Phone:563-386-9220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA332B00000X
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0098046Medicaid
IA0134783Medicaid
IA09804OtherWELLMARK BC BS
IA0134783Medicaid
IL=========001Medicaid
=========OtherHUMANA GOLD CHOICE PFFS
=========OtherHUMANA GOLD CHOICE PFFS