Provider Demographics
NPI:1366444739
Name:CORNELL ORTHOTICS AND PROSTHETICS, INC
Entity Type:Organization
Organization Name:CORNELL ORTHOTICS AND PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:978-922-2866
Mailing Address - Street 1:100 CUMMINGS CTR
Mailing Address - Street 2:SUITE 207H
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6115
Mailing Address - Country:US
Mailing Address - Phone:978-922-2866
Mailing Address - Fax:978-922-0277
Practice Address - Street 1:100 CUMMINGS CTR
Practice Address - Street 2:SUITE 207H
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6115
Practice Address - Country:US
Practice Address - Phone:978-922-2866
Practice Address - Fax:978-922-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA700854OtherHARVARD
MA1527975Medicaid
MA801259OtherTUFTS MEDICARE PREFERRED
MA801259OtherTUFTS
MA8853OtherNEIGHBORHOOD HEALTH PLAN
MA355654OtherBCBS
MA355654OtherBCBS