Provider Demographics
NPI:1962588228
Name:BRIDGEMAN BROTHERS MEDIQUIP
Entity type:Organization
Organization Name:BRIDGEMAN BROTHERS MEDIQUIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BRIDGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ATS CRTS
Authorized Official - Phone:478-742-0022
Mailing Address - Street 1:PO BOX 4383
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4383
Mailing Address - Country:US
Mailing Address - Phone:478-742-0022
Mailing Address - Fax:478-742-0211
Practice Address - Street 1:109 HWY 49
Practice Address - Street 2:SUITE 5
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-7853
Practice Address - Country:US
Practice Address - Phone:478-742-0022
Practice Address - Fax:478-742-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20012618227332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000977534AMedicaid
GA4239530001Medicare NSC