1093876278 NPI number — PANKOW ORTHOTICS & PROSTHETICS, LLC

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 1093876278 NPI number — PANKOW ORTHOTICS & PROSTHETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PANKOW 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:
1093876278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5489 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-651-0660
Provider Business Mailing Address Fax Number:
716-651-0668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5489 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14086-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-651-0660
Provider Business Practice Location Address Fax Number:
716-651-0668
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PANKOW
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
716-651-0660

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: 2908794 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00011248701 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5510441 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02804002 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5510441 . This is a "COMMUNITY BLUE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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