Provider Demographics
NPI:1649322512
Name:MD ORTHOTIC AND PROSTHETIC LAB
Entity type:Organization
Organization Name:MD ORTHOTIC AND PROSTHETIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOERTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-676-2276
Mailing Address - Street 1:8400 BROOKFIELD AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1707
Mailing Address - Country:US
Mailing Address - Phone:708-387-9700
Mailing Address - Fax:708-387-9704
Practice Address - Street 1:227 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:708-387-9700
Practice Address - Fax:708-387-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060008643213000063335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid