Provider Demographics
NPI:1770601999
Name:PRODIGY MEDICAL & HOSPITAL SUPPLIES, INC.
Entity type:Organization
Organization Name:PRODIGY MEDICAL & HOSPITAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EKAETE
Authorized Official - Middle Name:G
Authorized Official - Last Name:OBONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-1900
Mailing Address - Street 1:430 WEST 14TH STREET (LINCOLN HIGHWAY)
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2663
Mailing Address - Country:US
Mailing Address - Phone:708-747-1900
Mailing Address - Fax:708-747-8700
Practice Address - Street 1:430 WEST 14TH STREET (LINCOLN HIGHWAY)
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2663
Practice Address - Country:US
Practice Address - Phone:708-747-1900
Practice Address - Fax:708-747-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4319540001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #