Provider Demographics
NPI:1073712766
Name:MID-ATLANTIC PROSTHETICS-EAST, LLC
Entity Type:Organization
Organization Name:MID-ATLANTIC PROSTHETICS-EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-987-9113
Mailing Address - Street 1:1023 N CHARLES ST STE R3N
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5410
Mailing Address - Country:US
Mailing Address - Phone:240-401-8063
Mailing Address - Fax:667-210-2167
Practice Address - Street 1:1023 N CHARLES ST STE R3N
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5410
Practice Address - Country:US
Practice Address - Phone:240-401-8063
Practice Address - Fax:667-210-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC040028800Medicaid
MD5412838 00Medicaid
MD416699000Medicaid
MD416699000Medicaid