Provider Demographics
NPI:1508045238
Name:NORTH SHORE PEDORTHICS, LLC
Entity Type:Organization
Organization Name:NORTH SHORE PEDORTHICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, BOCO CO
Authorized Official - Phone:440-989-2799
Mailing Address - Street 1:4370 OBERLIN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-2942
Mailing Address - Country:US
Mailing Address - Phone:440-989-2799
Mailing Address - Fax:440-989-1127
Practice Address - Street 1:4370 OBERLIN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-2942
Practice Address - Country:US
Practice Address - Phone:440-989-2799
Practice Address - Fax:440-989-1127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLO 228 LPED 029222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2068622Medicaid
OH4305690001Medicare NSC