Provider Demographics
NPI:1982872669
Name:MEDISOURCE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MEDISOURCE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADREW
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:HENTY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:315-457-8337
Mailing Address - Street 1:145 DWIGHT PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1005
Mailing Address - Country:US
Mailing Address - Phone:315-457-8337
Mailing Address - Fax:
Practice Address - Street 1:145 DWIGHT PARK CIR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1005
Practice Address - Country:US
Practice Address - Phone:315-457-8337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6417590001Medicare NSC