Provider Demographics
NPI:1265431928
Name:SOUTHERN EXPRESS MEDICAL SUPPLY, INC
Entity type:Organization
Organization Name:SOUTHERN EXPRESS MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-376-0003
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:GEORGIANA
Mailing Address - State:AL
Mailing Address - Zip Code:36033
Mailing Address - Country:US
Mailing Address - Phone:334-376-0003
Mailing Address - Fax:334-376-5777
Practice Address - Street 1:125 CHURCH ST
Practice Address - Street 2:SUITE B
Practice Address - City:GEORGIANA
Practice Address - State:AL
Practice Address - Zip Code:36033
Practice Address - Country:US
Practice Address - Phone:334-376-0003
Practice Address - Fax:334-376-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51077252OtherBCBS PROVIDER NUMBER
AL305157OtherHEALTH INS CORP OF AL
AL000077252Medicaid
AL000077252Medicaid
AL========= 36033 0000OtherWPS TRICARE PROVIDER NUM
AL1191000001Medicare ID - Type UnspecifiedPROVIDER ID NUMBER