Provider Demographics
NPI:1093876278
Name:PANKOW ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:PANKOW ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:PANKOW
Authorized Official - Suffix:
Authorized Official - Credentials:BS,CPO
Authorized Official - Phone:716-651-0660
Mailing Address - Street 1:5489 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086
Mailing Address - Country:US
Mailing Address - Phone:716-651-0660
Mailing Address - Fax:716-651-0668
Practice Address - Street 1:5489 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-2219
Practice Address - Country:US
Practice Address - Phone:716-651-0660
Practice Address - Fax:716-651-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2908794OtherINDEPENDENT HEALTH
NY00011248701OtherUNIVERA
NY5510441OtherBLUE CROSS BLUE SHIELD
NY02804002Medicaid
NY5510441OtherCOMMUNITY BLUE
NY5510441OtherCOMMUNITY BLUE