MEDICARE: EVERGREEN SURGICAL SUPPLY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	1127183	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184711822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN SURGICAL SUPPLY INC.

Provider Business Mailing Address
First Line	:	5703 6TH AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3807
Country	:	US
Telephone Number	:	718-439-6038
Fax Number	:	718-439-6045

Provider Business Practice Location Address
First Line	:	5703 6TH AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3807
Country	:	US
Telephone Number	:	718-439-6038
Fax Number	:	718-439-6045

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHI HONG LI
Credential	:
Telephone Number	:	718-439-6038

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	08/26/2024

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