Provider Demographics
NPI:1538158902
Name:MEDSOURCE INC.
Entity type:Organization
Organization Name:MEDSOURCE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:803-926-2919
Mailing Address - Street 1:1311 AUGUSTA RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-6320
Mailing Address - Country:US
Mailing Address - Phone:803-926-2919
Mailing Address - Fax:
Practice Address - Street 1:1311 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6320
Practice Address - Country:US
Practice Address - Phone:803-926-2919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME993Medicaid
SC1126480001Medicare NSC