Provider Demographics
NPI:1851409932
Name:SRT PROSTHETICS & ORTHOTICS LLC
Entity Type:Organization
Organization Name:SRT PROSTHETICS & ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBENALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-633-3961
Mailing Address - Street 1:408 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46721-1179
Mailing Address - Country:US
Mailing Address - Phone:419-633-3961
Mailing Address - Fax:419-633-3981
Practice Address - Street 1:6475 WASHINGTON ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-855-0030
Practice Address - Fax:419-633-3961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL335E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid
WI5943820002Medicare NSC
IL5943820002Medicare NSC
IL4839250001Medicare NSC