Healthcare Provider Details

I. General information

NPI: 1356583488
Provider Name (Legal Business Name): AZER MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 E MAIN ST
GALESBURG IL
61401-4609
US

IV. Provider business mailing address

156 E MAIN ST
GALESBURG IL
61401-4609
US

V. Phone/Fax

Practice location:
  • Phone: 309-342-2937
  • Fax:
Mailing address:
  • Phone: 309-342-2937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. FAKHRY WILSON AZER
Title or Position: OWNER
Credential: P.T.
Phone: 309-344-3400