MEDICARE: STATE MEDICAL SUPPLY PROVIDER, 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	17769558	MO

General Provider Information

NPI Number	:	1720290281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE MEDICAL SUPPLY PROVIDER, INC

Provider Business Mailing Address
First Line	:	9109 LACKLAND RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63114-5410
Country	:	US
Telephone Number	:	314-426-5903
Fax Number	:	314-890-2110

Provider Business Practice Location Address
First Line	:	9109 LACKLAND RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63114-5410
Country	:	US
Telephone Number	:	314-426-5903
Fax Number	:	314-890-2110

Authorized Official
Title or Position	:	PESIDENT
Name	:	MR. DAVID SENDEROVICH
Credential	:
Telephone Number	:	314-426-5903

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	08/22/2020

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