Provider Demographics
NPI:1619265253
Name:HYDE PROSTHETICS AND ORTHOTICS, LLC
Entity Type:Organization
Organization Name:HYDE PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-474-8040
Mailing Address - Street 1:130 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1607
Mailing Address - Country:US
Mailing Address - Phone:478-474-8040
Mailing Address - Fax:478-474-8048
Practice Address - Street 1:130 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1607
Practice Address - Country:US
Practice Address - Phone:478-474-8040
Practice Address - Fax:478-474-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003209255AMedicaid
GA003107963AMedicaid