Provider Demographics
NPI:1831497056
Name:ROSS MEDICAL SUPPLY COMPANY, INC.
Entity type:Organization
Organization Name:ROSS MEDICAL SUPPLY COMPANY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-797-9099
Mailing Address - Street 1:1161 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1769
Mailing Address - Country:US
Mailing Address - Phone:563-386-9220
Mailing Address - Fax:563-386-0946
Practice Address - Street 1:1161 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1769
Practice Address - Country:US
Practice Address - Phone:563-386-9220
Practice Address - Fax:563-386-0946
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSS MEDICAL SUPPLY COMPANY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000088332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332B00000XMedicaid
IA0951806Medicaid