Provider Demographics
NPI:1295730216
Name:AMPUTEE CLINIC, INC.
Entity type:Organization
Organization Name:AMPUTEE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PT CP LPO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUM
Authorized Official - Middle Name:R
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CP, LPO
Authorized Official - Phone:239-437-4010
Mailing Address - Street 1:7051 CYPRESS TER
Mailing Address - Street 2:#108
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-8822
Mailing Address - Country:US
Mailing Address - Phone:239-437-4010
Mailing Address - Fax:239-437-4097
Practice Address - Street 1:7051 CYPRESS TER
Practice Address - Street 2:#108
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-8822
Practice Address - Country:US
Practice Address - Phone:239-437-4010
Practice Address - Fax:239-437-4097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009939684Medicaid
MI81750OtherNORTHWOOD (BC/BS MI DME)
TN204925600OtherTVA
MI8150OtherNORTHWOOD
TN1454256Medicaid
GA52895744 001OtherGEORGIA HEALTH PARTNERSHI
VA1295730216Medicaid
GA000914064AMedicaid
TN004016999OtherBC/BS OF TN
TN13125OtherPHP, CARITEN, PHP TENNCAR
TN4016999OtherBC/BS TN
GA000914064AMedicaid