MEDICARE: MEDISOURCE 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

General Provider Information

NPI Number	:	1689412520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDISOURCE SUPPLY INC

Provider Business Mailing Address
First Line	:	7703 N LAMAR BLVD STE 128
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78752-1003
Country	:	US
Telephone Number	:	512-375-4141
Fax Number	:

Provider Business Practice Location Address
First Line	:	7703 N LAMAR BLVD STE 128
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78752-1003
Country	:	US
Telephone Number	:	512-375-4141
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	KHALIL SHAFIQ
Credential	:
Telephone Number	:	512-375-4141

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	07/16/2024

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Directions to “MEDISOURCE SUPPLY INC ” Practice Location

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