Contract Details
Source One Medical Inc
Facility name
Source One Medical Inc
Provider ID
P000004866
NPI
1578672374
Tax ID
330860765
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
5480 Newport Dr Suite 47
Rolling Meadows, IL 60008
United States
County
Cook
Phone
8664162298 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Durable Medical Equipment & Medical Supplies
Map
Address