Provider Demographics
NPI:1487816583
Name:BI-STATE ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:BI-STATE ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIEDER
Authorized Official - Suffix:SR
Authorized Official - Credentials:COF
Authorized Official - Phone:314-843-2664
Mailing Address - Street 1:12660 LAMPLIGHTER SQR SHPPNG CTR
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12660 LAMPLIGHTER SQR SHPPNG CTR
Practice Address - Street 2:SUITE J
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2761
Practice Address - Country:US
Practice Address - Phone:314-843-2664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154462950Medicaid