Organization
MEDSOURCE LLC
Active
Organization
MEDSOURCE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ERIC ROHDE (OWNER)
(309) 664-7930
Entity
Organization
Contact information
Practice address
5300 S 108TH ST STE 19, HALES CORNERS, WI 53130-1368
(262) 446-4850
(262) 446-4851
Mailing address
PO BOX 1248, BLOOMINGTON, IL 61702-1248
(309) 664-7930
(309) 664-7931
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
203.001082
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
203.001082
LICENSE
IL
Enumeration date
07/27/2010
Last updated
11/30/2020
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