Provider Demographics
NPI:1487886537
Name:MEDSOURCE, LLC
Entity type:Organization
Organization Name:MEDSOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:EET
Authorized Official - Phone:757-220-5051
Mailing Address - Street 1:3909 MIDLANDS ROAD,
Mailing Address - Street 2:SUITE: B
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188
Mailing Address - Country:US
Mailing Address - Phone:757-220-5051
Mailing Address - Fax:757-220-5053
Practice Address - Street 1:3909 MIDLANDS ROAD,
Practice Address - Street 2:SUITE: B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188
Practice Address - Country:US
Practice Address - Phone:757-220-5051
Practice Address - Fax:757-220-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty