Provider Demographics
NPI:1467636209
Name:MOBILE RESPIRATORY&ANCILLARY SERVICE LLC
Entity type:Organization
Organization Name:MOBILE RESPIRATORY&ANCILLARY SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-926-1526
Mailing Address - Street 1:13011 W. M C N ICHOLS
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-4106
Mailing Address - Country:US
Mailing Address - Phone:313-926-1526
Mailing Address - Fax:313-491-0041
Practice Address - Street 1:13011 W. M C N ICHOLS
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4106
Practice Address - Country:US
Practice Address - Phone:313-862-2094
Practice Address - Fax:313-491-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4091540 TYPE87Medicaid
MI540H219070OtherBLUE CROSS BLUE SHIELD
MI4227480001Medicare NSC