Basic Information
Provider Information | |||||||||
NPI: | 1174625370 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MED-OX HOME MEDICAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARK II ENT., LTD | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4867 URBANA RD | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 455029503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373235764 | ||||||||
FaxNumber: | 9373232699 | ||||||||
Practice Location | |||||||||
Address1: | 8960 LEAVITT RD | ||||||||
Address2: |   | ||||||||
City: | ELYRIA | ||||||||
State: | OH | ||||||||
PostalCode: | 440354208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4409862215 | ||||||||
FaxNumber: | 4409862218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2006 | ||||||||
LastUpdateDate: | 08/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 9373235764 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 11076 | OH | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 2742876 | 05 | OH |   | MEDICAID |