Provider Demographics
NPI:1699055905
Name:SPRINGFIELD SURGICAL SUPPLY, INC.
Entity type:Organization
Organization Name:SPRINGFIELD SURGICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHATEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-528-7301
Mailing Address - Street 1:12715 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3421
Mailing Address - Country:US
Mailing Address - Phone:718-528-7301
Mailing Address - Fax:718-528-7399
Practice Address - Street 1:12715 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3421
Practice Address - Country:US
Practice Address - Phone:718-528-7301
Practice Address - Fax:718-528-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1249907332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02982736Medicaid
NY6516510001Medicare NSC