1073580759 NPI number — ADVANCED ORTHOTICS & PROSTHETICS , LLC

Table of content: (NPI 1073580759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073580759 NPI number — ADVANCED ORTHOTICS & PROSTHETICS , LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED ORTHOTICS & PROSTHETICS , LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073580759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 HOOSICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12180-6635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-279-4422
Provider Business Mailing Address Fax Number:
518-279-0033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 HOOSICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-6635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-279-4422
Provider Business Practice Location Address Fax Number:
518-279-0033
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLTON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
V
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
518-279-4422

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52371 . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: G72541 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 600337 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00040246000 . This is a "BLUE SHIELD NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10052506 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7104270 . This is a "AETNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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