Healthcare Provider Details

I. General information

NPI: 1245246560
Provider Name (Legal Business Name): PHOENIX MEDICAL SUPPLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HUDSON ST
HACKENSACK NJ
07601-6750
US

IV. Provider business mailing address

300 HUDSON ST
HACKENSACK NJ
07601-6750
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-0066
  • Fax: 201-441-9115
Mailing address:
  • Phone: 201-343-0066
  • Fax: 201-441-9115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0066371
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: WILLIAM MCMORROW SR.
Title or Position: OWNER
Credential:
Phone: 201-343-0066