MEDICARE: ONE SOURCE MEDICAL GROUP, 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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
2	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

General Provider Information

NPI Number	:	1902369267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE SOURCE MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	13910 LYNMAR BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3123
Country	:	US
Telephone Number	:	866-834-7473
Fax Number	:	877-490-9111

Provider Business Practice Location Address
First Line	:	6205 ABERCORN ST STE 101C
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31405-5540
Country	:	US
Telephone Number	:	866-834-7473
Fax Number	:	877-490-9111

Authorized Official
Title or Position	:	CEO
Name	:	DANIEL J ROBICHAUD
Credential	:
Telephone Number	:	866-834-7473

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	02/22/2024

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Directions to “ONE SOURCE MEDICAL GROUP, LLC ” Practice Location

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