Provider Demographics
NPI:1558345298
Name:INSTITUTE FOR PROSTHETIC ADVANCEMENT
Entity Type:Organization
Organization Name:INSTITUTE FOR PROSTHETIC ADVANCEMENT
Other - Org Name:I.P.A. PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:FREDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:850-784-0320
Mailing Address - Street 1:2315 RUTH HENTZ AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2260
Mailing Address - Country:US
Mailing Address - Phone:850-784-0320
Mailing Address - Fax:850-784-3661
Practice Address - Street 1:2315 RUTH HENTZ AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2260
Practice Address - Country:US
Practice Address - Phone:850-784-0320
Practice Address - Fax:850-784-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR13335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL951062100Medicaid
FLM2288OtherBCBS PROVIDER ID#
FL=========OtherTRICARE PROVIDER #
FL951062100Medicaid