Provider Demographics
NPI:1396969978
Name:PEDIATRIC MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:R
Authorized Official - Last Name:CAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-381-3060
Mailing Address - Street 1:2511 BROWNCROFT BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-1513
Mailing Address - Country:US
Mailing Address - Phone:585-381-3060
Mailing Address - Fax:585-381-3064
Practice Address - Street 1:2511 BROWNCROFT BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-1513
Practice Address - Country:US
Practice Address - Phone:585-381-3060
Practice Address - Fax:585-381-3064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5483700001Medicare NSC