Provider Demographics
NPI:1043769169
Name:MEDSOURCE ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:MEDSOURCE ORTHOTICS & PROSTHETICS, INC
Other - Org Name:HAMILTON PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-890-6824
Mailing Address - Street 1:3636 NORTH 3RD AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3904
Mailing Address - Country:US
Mailing Address - Phone:602-395-3354
Mailing Address - Fax:602-395-3361
Practice Address - Street 1:13203 N 103RD AVE STE J1&J2
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:602-395-3354
Practice Address - Fax:602-395-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier