Provider Demographics
NPI:1962587832
Name:MEDISERVE MEDICAL EQUIPMENT OF KINGSPORT, INC.
Entity type:Organization
Organization Name:MEDISERVE MEDICAL EQUIPMENT OF KINGSPORT, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3467
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-477-9806
Mailing Address - Fax:423-477-3571
Practice Address - Street 1:1183 SPRATLIN PARK DR
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-6205
Practice Address - Country:US
Practice Address - Phone:423-477-9806
Practice Address - Fax:423-477-3571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3547849Medicaid
0388440002Medicare NSC