Medisource Home Medical

Primary specialty

Customized Equipment (DME)Taxonomy code 332BC3200X

Legal business name

MEDISOURCE HOME MEDICAL

Practice address

975 Cobb Place Blvd NW Ste 113
Kennesaw, GA 30144-6848

Phone

(770) 528-9559

Fax

(770) 528-9309

NPI assigned

Jul 18, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Sergio Silva Sr.

Title

Owner

Phone

(770) 528-9559

Specialties & licenses 3

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Locations

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

{
    "created_epoch": "1153180800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602547200000",
    "number": "1770501736",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "975 COBB PLACE BLVD NW STE 113",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301446848",
            "telephone_number": "770-528-9559",
            "fax_number": "770-528-9309"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "975 COBB PLACE BLVD NW STE 113",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301446848",
            "telephone_number": "770-528-9559",
            "fax_number": "770-528-9309"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDISOURCE HOME MEDICAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-18",
        "last_updated": "2020-10-13",
        "certification_date": "2020-10-13",
        "status": "A",
        "authorized_official_last_name": "SILVA",
        "authorized_official_first_name": "SERGIO",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-528-9559",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Sr."
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332BC3200X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Customized Equipment",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "332BX2000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Oxygen Equipment & Supplies",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "52164995",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "341310291A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UHC",
            "identifier": "1023735",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Shamir McTizic
• Hollie Elizabeth Means-Beaman, LCSW
• Medcare Supply LLC
• Medical National Medical Supply Company, LLC
• Medici Medical Arts
• Tracy Medlin, OTR/L
• Diana Roya Mehrjooya
• Karma D Mehta, PA-C
• Maddison Capri Meijome, LICSW
• Hawii Mekonnen, OTR/L

• Customized Equipment (DME) in Kennesaw, GA
• Providers in Kennesaw, GA by specialty
• Customized Equipment (DME) in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.