Basic Information
| Provider Information | |||||||||
| NPI: | 1134264286 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGEMARK MEDICAL SUPPLY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 LAKE ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603011049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129942306 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1140 LAKE ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603011049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129942306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MBR | ||||||||
| AuthorizedOfficialTelephone: | 3129942306 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.