Basic Information
| Provider Information | |||||||||
| NPI: | 1568465938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH COMPLEX MEDICAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTH COMPLEX MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 220 W GERMANTOWN PIKE STE 250 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106306357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 84 PROGRESS LN | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067053863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037537778 | ||||||||
| FaxNumber: | 2037537779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 0040159013 | 05 | CT | MEDICAID |