Provider Demographics
NPI:1548700024
Name:FIRST SOURCE CATHETER, INC.
Entity type:Organization
Organization Name:FIRST SOURCE CATHETER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-839-2904
Mailing Address - Street 1:1690 REDI RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9704
Mailing Address - Country:US
Mailing Address - Phone:470-839-2904
Mailing Address - Fax:
Practice Address - Street 1:1690 REDI RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9704
Practice Address - Country:US
Practice Address - Phone:470-839-2904
Practice Address - Fax:470-839-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003199056AMedicaid