1568466068 NPI number — EASTSIDE ORTHOTICS & PROSTHETICS 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 1568466068 NPI number — EASTSIDE ORTHOTICS & PROSTHETICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE ORTHOTICS & PROSTHETICS 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:
1568466068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 COMMERCE DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
RIVERHEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11901-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-727-8735
Provider Business Mailing Address Fax Number:
631-727-6834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
388 WESTCHESTER AVE
Provider Second Line Business Practice Location Address:
STE 1J
Provider Business Practice Location Address City Name:
PORT CHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10573-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-935-1185
Provider Business Practice Location Address Fax Number:
914-935-1187
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FLYNN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-727-8735

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: 02247914 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003104578 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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