Provider Demographics
NPI:1184607335
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:616-502-6488
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:STE 1100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8007
Mailing Address - Fax:616-840-9504
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:STE 1100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8007
Practice Address - Fax:616-840-9752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI335E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI530D105100OtherBLUE CROSS UPIN
MI851722744Medicaid
MI0402260001Medicare NSC