Provider Demographics
NPI:1437198322
Name:TOM WATSON'S PROSTHETICS AND ORTHOTICS LAB, INC.
Entity Type:Organization
Organization Name:TOM WATSON'S PROSTHETICS AND ORTHOTICS LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BIONIC
Authorized Official - Prefix:
Authorized Official - First Name:SUMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAXENA
Authorized Official - Suffix:
Authorized Official - Credentials:CP BOCO
Authorized Official - Phone:219-791-9200
Mailing Address - Street 1:3803 E LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5809
Mailing Address - Country:US
Mailing Address - Phone:197-919-2002
Mailing Address - Fax:312-268-5389
Practice Address - Street 1:2819 W 4TH ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-0237
Practice Address - Country:US
Practice Address - Phone:270-684-6128
Practice Address - Fax:270-684-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1024483335E00000X, 335E00000X
KY335E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100004070BMedicaid
KY90060302Medicaid
KY000000066285OtherANTHEM BLUE CROSS BLUE SH
KY1024483OtherANCILLARY CARE MANAGEMENT
IL=========001Medicaid
IN0207930001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
KY000000066285OtherANTHEM BLUE CROSS BLUE SH