MEDICARE: IDEAL 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

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528144060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	2658 W BROAD ST STE 100
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-3329
Country	:	US
Telephone Number	:	614-238-0878
Fax Number	:	614-343-7110

Provider Business Practice Location Address
First Line	:	2872 WEST BROAD STREET STE 101
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-2645
Country	:	US
Telephone Number	:	614-238-0878
Fax Number	:	614-343-7110

Authorized Official
Title or Position	:	CEO
Name	:	LEONID KRUPOVLYANSKIY
Credential	:
Telephone Number	:	614-238-0878

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	08/28/2013

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