Provider Demographics
NPI:1104962547
Name:STATEWIDE MEDICAL AND SURGICAL SUPPLIES INC.
Entity type:Organization
Organization Name:STATEWIDE MEDICAL AND SURGICAL SUPPLIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MISS
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:DESORMEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-257-8810
Mailing Address - Street 1:9602 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4808
Mailing Address - Country:US
Mailing Address - Phone:718-257-8810
Mailing Address - Fax:718-257-8806
Practice Address - Street 1:9602 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4813
Practice Address - Country:US
Practice Address - Phone:718-257-8810
Practice Address - Fax:718-257-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1118484332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291367Medicaid
NY4413320001Medicare NSC