Provider Demographics
NPI:1255676342
Name:WHITESIDE ORTHOTIC AND PROSTHETIC GROUP, INC.
Entity Type:Organization
Organization Name:WHITESIDE ORTHOTIC AND PROSTHETIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:330-360-0900
Mailing Address - Street 1:3267 OLDE WINTER TRL
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2893
Mailing Address - Country:US
Mailing Address - Phone:330-360-0900
Mailing Address - Fax:
Practice Address - Street 1:8571 FOXWOOD CT
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-4313
Practice Address - Country:US
Practice Address - Phone:330-360-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLO-151335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier