Provider Demographics
NPI:1851395388
Name:EASTSIDE ORTHOTICS & PROSTHETICS INC
Entity Type:Organization
Organization Name:EASTSIDE ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:631-727-8735
Mailing Address - Street 1:889 HARRISON AVE
Mailing Address - Street 2:STE 2A
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2090
Mailing Address - Country:US
Mailing Address - Phone:631-727-8735
Mailing Address - Fax:631-727-6834
Practice Address - Street 1:417 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4414
Practice Address - Country:US
Practice Address - Phone:212-326-8501
Practice Address - Fax:212-326-8538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02247890Medicaid
NY0317640001Medicare NSC