MEDICARE: VICTORY MEDICAL SUPPLY INC

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	203000788	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001636799	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1245375179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	8156 S COTTAGE GROVE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-5104
Country	:	US
Telephone Number	:	773-783-8666
Fax Number	:	773-783-8664

Provider Business Practice Location Address
First Line	:	8156 S COTTAGE GROVE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-5104
Country	:	US
Telephone Number	:	773-783-8666
Fax Number	:	773-783-8664

Authorized Official
Title or Position	:	PRISIDENT
Name	:	MISS VICKY U ANADUMAKA
Credential	:
Telephone Number	:	773-783-8666

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	03/11/2008

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Directions to “VICTORY MEDICAL SUPPLY INC ” Practice Location

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