Provider Demographics
NPI:1720146996
Name:FIVE STAR MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:FIVE STAR MEDICAL SUPPLIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-332-1334
Mailing Address - Street 1:1004 STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4856
Mailing Address - Country:US
Mailing Address - Phone:563-332-1334
Mailing Address - Fax:563-332-1359
Practice Address - Street 1:1004 STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4856
Practice Address - Country:US
Practice Address - Phone:563-332-1334
Practice Address - Fax:563-332-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA182038180332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0417774Medicaid
IL001596360OtherBLUE CROSS BLUE SHIELD
IA20064OtherBLUE CROSS BLUE SHIELD
IL336664976001Medicaid
4700250001Medicare NSC