Healthcare Provider Details

I. General information

NPI: 1164062543
Provider Name (Legal Business Name): EASTERN MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DUPONT ST STE 22
PLAINVIEW NY
11803-1688
US

IV. Provider business mailing address

1859 LEONARD LN
MERRICK NY
11566-4933
US

V. Phone/Fax

Practice location:
  • Phone: 516-238-2283
  • Fax:
Mailing address:
  • Phone: 866-367-6682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SCOTT C TILLMAN
Title or Position: OWNER
Credential:
Phone: 516-238-2283