Provider Demographics
NPI:1962683144
Name:FAIRCHILD PEDORTHOTIC/ORTHOTIC SERVICES LLC
Entity Type:Organization
Organization Name:FAIRCHILD PEDORTHOTIC/ORTHOTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:607-348-0343
Mailing Address - Street 1:477 STATE ST
Mailing Address - Street 2:COLONAIL PLAZA
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-2341
Mailing Address - Country:US
Mailing Address - Phone:607-348-0343
Mailing Address - Fax:607-348-0347
Practice Address - Street 1:477 STATE ST
Practice Address - Street 2:COLONAIL PLAZA
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2341
Practice Address - Country:US
Practice Address - Phone:607-348-0343
Practice Address - Fax:607-348-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0003702335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02408313Medicaid
NY02408313Medicaid