MEDICARE: MIDWEST MEDICAL ALLIANCE 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

General Provider Information

NPI Number	:	1225371487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MEDICAL ALLIANCE LLC

Provider Business Mailing Address
First Line	:	PO BOX 33
Second Line	:
City	:	GROVELAND
State	:	IL
Zip	:	61535-0033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 NICHOLAS DR
Second Line	:
City	:	GROVELAND
State	:	IL
Zip	:	61535-9564
Country	:	US
Telephone Number	:	630-697-0443
Fax Number	:	888-455-0899

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. NICHOLAS SMITH
Credential	:
Telephone Number	:	630-697-0443

Provider Enumeration Date	:	04/05/2013
Last Update Date	:	04/05/2013

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