1336172196 NPI number — MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC

Table of content: (NPI 1336172196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336172196 NPI number — MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CENTER ORTHOTICS AND 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:
6
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:
1336172196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 LINDEN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20910-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-585-5347
Provider Business Mailing Address Fax Number:
301-585-4383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 REEDSDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-698-6334
Provider Business Practice Location Address Fax Number:
617-698-3260
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CORCORAN
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-585-5347

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102441600 . This is a "US DEPT OF LABOR PROV ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 240254 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3137161 . This is a "CIGNA PROVIDER ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 801088 . This is a "TUFTS HEALTH PLAN PROV ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 800550 . This is a "HARVARD PILGRIM PROV ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1501003 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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