Provider Demographics
NPI:1336172196
Name:MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:MEDICAL CENTER ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:301-585-5347
Mailing Address - Street 1:2421 LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1230
Mailing Address - Country:US
Mailing Address - Phone:301-585-5347
Mailing Address - Fax:301-585-4383
Practice Address - Street 1:199 REEDSDALE RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186
Practice Address - Country:US
Practice Address - Phone:617-698-6334
Practice Address - Fax:617-698-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA102441600OtherUS DEPT OF LABOR PROV ID
MA240254OtherBLUE CROSS BLUE SHIELD ID
MA3137161OtherCIGNA PROVIDER ID
MA801088OtherTUFTS HEALTH PLAN PROV ID
MA800550OtherHARVARD PILGRIM PROV ID
MA1501003Medicaid
MA1501003Medicaid