Provider Demographics
NPI:1679625560
Name:MD ORTHOTIC AND PROSTHETIC LABORATORIES, INC.
Entity Type:Organization
Organization Name:MD ORTHOTIC AND PROSTHETIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOERTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:309-676-2276
Mailing Address - Street 1:741 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1953
Mailing Address - Country:US
Mailing Address - Phone:800-334-5705
Mailing Address - Fax:888-663-6322
Practice Address - Street 1:8400 BROOKFIELD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513
Practice Address - Country:US
Practice Address - Phone:888-635-2271
Practice Address - Fax:888-635-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060008643213000063335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL0258550001Medicare NSC