Provider Demographics
NPI:1750565479
Name:GRANITE STATE ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:GRANITE STATE ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:II
Authorized Official - Credentials:CO, CPED
Authorized Official - Phone:603-228-7159
Mailing Address - Street 1:280 PLEASANT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2553
Mailing Address - Country:US
Mailing Address - Phone:603-228-7159
Mailing Address - Fax:603-225-4265
Practice Address - Street 1:280 PLEASANT ST STE 3
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2553
Practice Address - Country:US
Practice Address - Phone:603-228-7159
Practice Address - Fax:603-225-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2264576OtherCIGNA
NH30761501Medicaid
NH706167OtherHARVARD PILGRIM
NH4665514OtherAETNA
NH12Y002242NH01OtherANTHEM
NH2264576OtherCIGNA
NH12Y002242NH01OtherANTHEM