Provider Demographics
NPI:1295780856
Name:WASHTENAW MEDICAL SUPPLIES
Entity type:Organization
Organization Name:WASHTENAW MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BUBENHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, CFOM
Authorized Official - Phone:734-971-1862
Mailing Address - Street 1:2835 CARPENTER RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1172
Mailing Address - Country:US
Mailing Address - Phone:734-971-1862
Mailing Address - Fax:734-971-1553
Practice Address - Street 1:2835 CARPENTER RD
Practice Address - Street 2:SUITE #1
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1172
Practice Address - Country:US
Practice Address - Phone:734-971-1862
Practice Address - Fax:734-971-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100137OtherCARE CHOICES HMO ID #
MI4259366Medicaid
MI0H10409OtherBLUE CROSS OF MICHIGAN ID
MI0H10409OtherBLUE CROSS OF MICHIGAN ID