Provider Demographics
NPI:1053318022
Name:EASTSIDE ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:EASTSIDE ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:631-727-8735
Mailing Address - Street 1:889 HARRISON AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2090
Mailing Address - Country:US
Mailing Address - Phone:631-727-8735
Mailing Address - Fax:631-727-6834
Practice Address - Street 1:889 HARRISON AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2090
Practice Address - Country:US
Practice Address - Phone:631-727-8735
Practice Address - Fax:631-727-6834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02247905Medicaid
NY0317640003Medicare NSC