Provider Demographics
NPI:1982608493
Name:EASTSIDE ORTHOTICS AND PROSTHETICS, INC.
Entity Type:Organization
Organization Name:EASTSIDE ORTHOTICS AND PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:631-727-8735
Mailing Address - Street 1:34 COMMERCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3174
Mailing Address - Country:US
Mailing Address - Phone:631-727-8735
Mailing Address - Fax:631-727-6834
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:VC333
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-3275
Practice Address - Fax:212-305-5927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01052611Medicaid
0317640002Medicare NSC