Basic Information
| Provider Information | |||||||||
| NPI: | 1558323220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOTIC PROSTHETIC CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8330 PROFESSIONAL HILL DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036985007 | ||||||||
| FaxNumber: | 7032079395 | ||||||||
| Practice Location | |||||||||
| Address1: | 8330 PROFESSIONAL HILL DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036985007 | ||||||||
| FaxNumber: | 7032079395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | CORCORAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3019060603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPO | ||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 033067700 | 05 | DC | MEDICAID | 9190074 | 05 | VA | MEDICAID | 229699 | 01 | MD | MAMSI ALLIANCE PROVIDER | OTHER | 326970 | 01 | VA | ANTHEM BCBS PROVIDER | OTHER | 25459 | 01 | MD | KASIER PROVIER | OTHER | 09030 | 05 | VA | MEDICAID | 9133062 | 05 | VA | MEDICAID |