Provider Demographics
NPI:1043356256
Name:EASTERN PEDORTHICS, INC.
Entity Type:Organization
Organization Name:EASTERN PEDORTHICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:609-737-7701
Mailing Address - Street 1:7 ROUTE 31 N
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-1612
Mailing Address - Country:US
Mailing Address - Phone:609-737-7701
Mailing Address - Fax:609-737-7705
Practice Address - Street 1:7 ROUTE 31 N
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-1612
Practice Address - Country:US
Practice Address - Phone:609-737-7701
Practice Address - Fax:609-737-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6757502Medicaid
NJ823763OtherAETNA PROVIDER NUMBER
NJ6757502Medicaid