Organization
MEDISOURCE HOME MEDICAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SERGIO SILVA SR. (OWNER)
(770) 528-9559
Entity
Organization
Contact information
Practice address
975 COBB PLACE BLVD NW STE 113, KENNESAW, GA 30144-6848
(770) 528-9559
(770) 528-9309
Mailing address
975 COBB PLACE BLVD NW STE 113, KENNESAW, GA 30144-6848
(770) 528-9559
(770) 528-9309
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332BC3200X
Customized Equipment (DME)
Primary
—
—
332BX2000X
Oxygen Equipment & Supplies (DME)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1023735
UHC
GA
05
—
341310291A
—
GA
01
—
52164995
BCBS
GA
Enumeration date
07/18/2006
Last updated
10/13/2020
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