Provider Demographics
NPI:1154462950
Name:BI-STATE ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:BI-STATE ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:314-843-2664
Mailing Address - Street 1:12660 LAMPLIGHTER SQR SHPPNG CTR
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2761
Mailing Address - Country:US
Mailing Address - Phone:314-843-2664
Mailing Address - Fax:314-842-3866
Practice Address - Street 1:6400 W MAIN ST
Practice Address - Street 2:SUITE 3G
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3806
Practice Address - Country:US
Practice Address - Phone:314-843-2664
Practice Address - Fax:314-842-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8221629OtherBCBS OF IL
MO122758OtherBCBS OF MO
MO122758OtherBCBS OF MO
IL=========001Medicaid