1083654503 NPI number — LIBERTY ORTHOTICS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083654503 NPI number — LIBERTY ORTHOTICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY ORTHOTICS, INC.
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:
1083654503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HYDE PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11040-4925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-326-6786
Provider Business Mailing Address Fax Number:
516-326-6784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HYDE PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11040-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-326-6786
Provider Business Practice Location Address Fax Number:
516-326-6784
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRANDT
Authorized Official First Name:
FRANCIS
Authorized Official Middle Name:
XAVIER
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
516-326-6786

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000023042 . This is a "AFFINITY PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3125 . This is a "NY PRESBYTERIAN SELECT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02010093 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000412358262 . This is a "HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 04072200123 . This is a "FIDELIS HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1211801 . This is a "COMMUNITY PREMIER PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2021095 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C4927 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10532 . This is a "HUDSON HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 57P0182 . This is a "ABC HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10093592 . This is a "CDPHP PROVIDER #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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