Basic Information
| Provider Information | |||||||||
| NPI: | 1336172196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC | ||||||||
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| OtherOrganizationName: | SOUTH SHORE ORTHOPEDIC LABS INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2421 LINDEN LN | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015855347 | ||||||||
| FaxNumber: | 3015854383 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 REEDSDALE RD | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176986334 | ||||||||
| FaxNumber: | 6176983260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | CORCORAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3015855347 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPO | ||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist | 225000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 102441600 | 01 | MA | US DEPT OF LABOR PROV ID | OTHER | 240254 | 01 | MA | BLUE CROSS BLUE SHIELD ID | OTHER | 3137161 | 01 | MA | CIGNA PROVIDER ID | OTHER | 801088 | 01 | MA | TUFTS HEALTH PLAN PROV ID | OTHER | 800550 | 01 | MA | HARVARD PILGRIM PROV ID | OTHER | 1501003 | 05 | MA | MEDICAID |