MEDICARE: MID SOUTH ORTHOPEDIC SUPPLIES, 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	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1669526224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID SOUTH ORTHOPEDIC SUPPLIES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1835
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76244-1835
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12008 RACHEL LEA LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-9137
Country	:	US
Telephone Number	:	817-439-5060
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PATRICK HALL
Credential	:
Telephone Number	:	817-832-0467

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/04/2008

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