Basic Information
| Provider Information | |||||||||
| NPI: | 1891308805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCSHAN MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327680639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212975003 | ||||||||
| FaxNumber: | 3212565176 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 S BAY ST STE B | ||||||||
| Address2: | |||||||||
| City: | EUSTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327266300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212975003 | ||||||||
| FaxNumber: | 3212565176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCSHAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3212975003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.