Provider Demographics
NPI:1720080005
Name:CANTON ORTHOTIC LABORATORY INC
Entity type:Organization
Organization Name:CANTON ORTHOTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LICENSED ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SIMKO
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:330-454-2081
Mailing Address - Street 1:811 12TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-1927
Mailing Address - Country:US
Mailing Address - Phone:330-454-2081
Mailing Address - Fax:330-454-9568
Practice Address - Street 1:811 12TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-1927
Practice Address - Country:US
Practice Address - Phone:330-454-2081
Practice Address - Fax:330-454-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
OH335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000155415OtherANTHEM PROVIDER NUMBER
OH0291143Medicaid
OH=========026OtherCARE SOURCE CAID HMO
OH=========003OtherMEDICAL MUTUAL PROVIDER #
OH000000155415OtherANTHEM PROVIDER NUMBER