Provider Demographics
NPI:1851389449
Name:PROSTHETIC ORTHOTIC SPECIALIST INC
Entity Type:Organization
Organization Name:PROSTHETIC ORTHOTIC SPECIALIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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:309-676-2276
Mailing Address - Fax:309-676-0486
Practice Address - Street 1:701 NE JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-688-9549
Practice Address - Fax:309-676-0486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-09
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05770602OtherBLUE CROSS BLUE SHIELD
IL=========002Medicaid
IL05770602OtherBLUE CROSS BLUE SHIELD