Provider Demographics
NPI:1871591974
Name:MEDIDEX LLC
Entity type:Organization
Organization Name:MEDIDEX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-880-0473
Mailing Address - Street 1:220 W GERMANTOWN PIKE STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1437
Mailing Address - Country:US
Mailing Address - Phone:610-630-6357
Mailing Address - Fax:
Practice Address - Street 1:1711 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1322
Practice Address - Country:US
Practice Address - Phone:417-883-1400
Practice Address - Fax:417-883-2663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11714034332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621674308Medicaid