Provider Demographics
NPI:1871711358
Name:BOARDMAN MEDICAL SUPPLY CO
Entity type:Organization
Organization Name:BOARDMAN MEDICAL SUPPLY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:IVANY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-545-6700
Mailing Address - Street 1:300 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-2538
Mailing Address - Country:US
Mailing Address - Phone:330-545-6700
Mailing Address - Fax:330-545-5555
Practice Address - Street 1:719 E STATE ST
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:PA
Practice Address - Zip Code:16146-3327
Practice Address - Country:US
Practice Address - Phone:330-545-6700
Practice Address - Fax:330-545-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007430630006Medicaid
PA1007430630006Medicaid