Provider Demographics
NPI:1275605461
Name:MEDSOURCE ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:MEDSOURCE ORTHOTICS & PROSTHETICS
Other - Org Name:HAMILTON PROSTHETIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-255-5202
Mailing Address - Street 1:3636 N 3RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3938
Mailing Address - Country:US
Mailing Address - Phone:602-395-3354
Mailing Address - Fax:602-395-3361
Practice Address - Street 1:9305 W. THOMAS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037
Practice Address - Country:US
Practice Address - Phone:623-738-0301
Practice Address - Fax:602-395-3361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDSOURCE ORTHOTICS & PROSTHETICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-14
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
3956490002Medicare NSC
AZ3956490002Medicare NSC