Provider Demographics
NPI:1730354531
Name:MEDSOURCE LLC
Entity type:Organization
Organization Name:MEDSOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-664-7930
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-1248
Mailing Address - Country:US
Mailing Address - Phone:309-664-7930
Mailing Address - Fax:309-664-7931
Practice Address - Street 1:200 HOWARD AVE STE 206
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-5907
Practice Address - Country:US
Practice Address - Phone:773-265-7670
Practice Address - Fax:773-265-7674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.001082332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203.001082OtherLICENSE
IL203.001082OtherLICENSE
IL=========001Medicaid