MEDICARE: KENTUCKY MEDICAL 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	2080P0006X	Developmental - Behavioral Pediatrics Physician		KY
2	332B00000X	Durable Medical Equipment & Medical Supplies	177855	KY
3	332BX2000X	Oxygen Equipment & Supplies (DME)	175293	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45907789	OTHER	KY	EPSDT PROVIDER ID NO.
2	7542	OTHER	KY	CHA PROVIDER ID NO.
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	000000070314	OTHER	KY	BC PROVIDER ID NO.

General Provider Information

NPI Number	:	1942205943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENTUCKY MEDICAL SUPPLY, INC.

Provider Business Mailing Address
First Line	:	3325 BARTLETT BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32811-6428
Country	:	US
Telephone Number	:	407-206-0040
Fax Number	:	407-206-0010

Provider Business Practice Location Address
First Line	:	102 CASTLE RIDGE DR
Second Line	:
City	:	EDMONTON
State	:	KY
Zip	:	42129
Country	:	US
Telephone Number	:	270-432-0957
Fax Number	:	270-432-0957

Authorized Official
Title or Position	:	CEO/ PRESIDENT
Name	:	MR. STEPHEN P GRIGGS
Credential	:
Telephone Number	:	407-206-0040

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	06/15/2020

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