Provider Demographics
NPI:1356343651
Name:NORTHEAST ORTHOTICS AND PROSTHETICS INC
Entity type:Organization
Organization Name:NORTHEAST ORTHOTICS AND PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARICH
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:401-444-5477
Mailing Address - Street 1:2 DUDLEY ST
Mailing Address - Street 2:STE 161
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3236
Mailing Address - Country:US
Mailing Address - Phone:401-444-5477
Mailing Address - Fax:401-444-4237
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:STE 161
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-444-5477
Practice Address - Fax:401-444-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009539Medicaid
RI9009539Medicaid