Healthcare Provider Details

I. General information

NPI: 1871591974
Provider Name (Legal Business Name): MEDIDEX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 E SUNSHINE ST
SPRINGFIELD MO
65804-1322
US

IV. Provider business mailing address

555 E NORTH LN STE 5075
CONSHOHOCKEN PA
19428-2490
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-1400
  • Fax: 417-883-2663
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number11714034
License Number StateMO

VIII. Authorized Official

Name: WENDY RUSSALESI
Title or Position: CCO
Credential:
Phone: 484-246-9499