Provider Demographics
NPI:1407834369
Name:ORTHOTIC & PROSTHETIC SPECIALTIES, INC.
Entity Type:Organization
Organization Name:ORTHOTIC & PROSTHETIC SPECIALTIES, INC.
Other - Org Name:ORTHOTIC SPECIALTIES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GAUDIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-531-2773
Mailing Address - Street 1:20650 LAKELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-3241
Mailing Address - Country:US
Mailing Address - Phone:216-531-2773
Mailing Address - Fax:216-531-5376
Practice Address - Street 1:20650 LAKELAND BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-3241
Practice Address - Country:US
Practice Address - Phone:216-531-2773
Practice Address - Fax:216-531-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-02
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0209983Medicaid
OH18961OtherQUALCHOICE
OH8200099OtherUNITED HEALTHCARE
OH000000155387OtherANTHEM
OH8200099OtherUNITED HEALTHCARE
OH18961OtherQUALCHOICE
OH0170060001Medicare UPIN