Basic Information
| Provider Information | |||||||||
| NPI: | 1720751787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2409 LINDEN LN | ||||||||
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| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015855347 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8330 PROFESSIONAL HILL DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036985007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | CORCORAN | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3015855347 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPO | ||||||||
| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
No ID Information.