Specialized Medical Devices, Inc.

Contacts

Phone	+1 407-515-2070
Phone	+1 256-536-4161
Fax	2565367638

Authorized person

Name	WENDY RUSSALESI
Role	AUTHORIZED OFFICIAL, OFFICER
Phone	4842469499

Taxonomy

Taxonomy Code	332BX2000X - Oxygen Equipment & Supplies (DME)
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	000056785
State	AL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2021-06-30
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2021-06-30
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2020-07-22
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2020-07-22
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2019-10-14
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2019-10-14
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2018-10-10
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2018-10-10
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2017-09-27
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2017-09-27
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	544 TILL DAVIS ROAD, LANGSTON, AL, 35755

Signature of

Role	Plan administrator
Date	2016-10-05
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2016-10-05
Name of individual signing	LINDA KILLIAN

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-09-01
Business code	812990
Sponsor’s telephone number	2565367676
Plan sponsor’s address	3001 12TH AVENUE SW, HUNTSVILLE, AL, 35805

Signature of

Role	Plan administrator
Date	2015-08-26
Name of individual signing	LINDA KILLIAN
Role	Employer/plan sponsor
Date	2015-08-26
Name of individual signing	LINDA KILLIAN

Legal Name	SPECIALIZED MEDICAL DEVICES INC
DBA Name	-
Physical Address	2905 WESTCORP BLVD SUITE 112, HUNTSVILLE, AL, 35805, US
Mailing Address	2905 WESTCORP BLVD SUITE 112, HUNTSVILLE, AL, 35805, US
Phone	(256) 536-7676
Fax	(256) 536-7638
E-mail	-

Safety Measurement System - All Transportation

Total Number of Inspections for the measurement period (24 months)	0
Driver Fitness BASIC Serious Violation Indicator	No
Vehicle Maintenance BASIC Acute/Critical Indicator	No
Unsafe Driving BASIC Acute/Critical Indicator	No
Driver Fitness BASIC Roadside Performance measure value	0
Hours-of-Service (HOS) Compliance BASIC Roadside Performance measure value	0
Total Number of Driver Inspections for the measurment period	0
Vehicle Maintenance BASIC Roadside Performance measure value	0
Total Number of Vehicle Inspections for the measurement period	0
Controlled Substances and Alcohol BASIC Roadside Performance measure value	0
Unsafe Driving BASIC Roadside Performance Measure Value	0
Number of inspections with at least one Driver Fitness BASIC violation	0
Number of inspections with at least one Hours-of-Service BASIC violation	0
Total Number of Driver Inspections containing at least one Driver Out-of-Service Violation	0
Number of inspections with at least one Vehicle Maintenance BASIC violation	0
Total Number of Vehicle Inspections containing at least one Vehicle Out-of-Service violation	0
Number of inspections with at least one Controlled Substances and Alcohol BASIC violation	0
Number of inspections with at least one Unsafe Driving BASIC violation	0