Medsource Medical, LLC

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

License

8119067-1714 Issued in UT

Legal business name

MEDSOURCE MEDICAL, LLC

Doing business as

Ingram Medical

Practice address

9883 S 500 W
Sandy, UT 84070-2561

Phone

(877) 577-7767

Fax

(801) 727-0092

NPI assigned

Oct 27, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Robert Rose

Title

Coo

Phone

(877) 577-7767

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Ingram Medical Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1319673600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1319673600000",
    "number": "1679859169",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9883 S 500 W",
            "city": "SANDY",
            "state": "UT",
            "postal_code": "840702561",
            "telephone_number": "877-577-7767",
            "fax_number": "801-727-0092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9883 S 500 W",
            "city": "SANDY",
            "state": "UT",
            "postal_code": "840702561",
            "telephone_number": "877-577-7767",
            "fax_number": "801-727-0092"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDSOURCE MEDICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-27",
        "last_updated": "2011-10-27",
        "status": "A",
        "authorized_official_last_name": "ROSE",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "877-577-7767"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "UT",
            "license": "8119067-1714",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "4612138",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ingram Medical",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Durable Medical Equipment & Medical Supplies in Sandy, UT
• Providers in Sandy, UT by specialty
• Durable Medical Equipment & Medical Supplies in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 27, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.