MEDICARE: SPARTAN MEDICAL SUPPLIES LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5404010180	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1073523163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARTAN MEDICAL SUPPLIES LLC

Provider Business Mailing Address
First Line	:	8849 PINE ISLAND COURT SOUTH
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9570
Country	:	US
Telephone Number	:	269-668-6066
Fax Number	:	269-924-0675

Provider Business Practice Location Address
First Line	:	8849 PINE ISLAND COURT SOUTH
Second Line	:
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9570
Country	:	US
Telephone Number	:	269-668-6066
Fax Number	:	269-924-0675

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. ADAM R GRASSL
Credential	:
Telephone Number	:	269-668-6066

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/06/2016

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