MEDICARE: CARDIOSOM, 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	332BX2000X	Oxygen Equipment & Supplies (DME)	69000011A	IN

General Provider Information

NPI Number	:	1326058389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOSOM, LLC

Provider Business Mailing Address
First Line	:	615 W. CARMEL DR.
Second Line	:	SUITE 100
City	:	CARMEL
State	:	IN
Zip	:	46032-5504
Country	:	US
Telephone Number	:	317-706-1080
Fax Number	:	317-574-8674

Provider Business Practice Location Address
First Line	:	1625 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1535
Country	:	US
Telephone Number	:	260-436-2261
Fax Number	:	260-436-0092

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	MR. JAY JARRELL
Credential	:
Telephone Number	:	317-706-1080

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/10/2010

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