Provider Demographics
NPI:1952489163
Name:PROGRESSIVE ORTHOTICS LTD
Entity Type:Organization
Organization Name:PROGRESSIVE ORTHOTICS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO BOCP
Authorized Official - Phone:631-732-5556
Mailing Address - Street 1:280 MIDDLE COUNTRY RD STE G
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2532
Mailing Address - Country:US
Mailing Address - Phone:631-732-5556
Mailing Address - Fax:631-732-0218
Practice Address - Street 1:280 MIDDLE COUNTRY RD STE G
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2532
Practice Address - Country:US
Practice Address - Phone:631-732-5556
Practice Address - Fax:631-732-0218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROGRESSIVE ORTHOTICS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00615045Medicaid
NY0228410001Medicare NSC