Basic Information
Provider Information | |||||||||
NPI: | 1972882959 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RSI MEDICAL SUPPLY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNITED MEDICAL SUPPLY GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2636 S LOOP W | ||||||||
Address2: | SUITE 675 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770545638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134407149 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2636 S LOOP W | ||||||||
Address2: | SUITE 675 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770545638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134407149 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2011 | ||||||||
LastUpdateDate: | 10/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUCERI | ||||||||
AuthorizedOfficialFirstName: | JOE | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3144477747 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 704498 | 05 | AZ |   | MEDICAID | 295033902 | 05 | TX |   | MEDICAID | 295033901 | 05 | TX |   | MEDICAID |