MEDICARE: MID-MISSOURI ORTHOTICS & PROSTHETICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	522024	OTHER	MO	HEALTHLINK
2	41486	OTHER	MO	HEALTHCARE USA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	166056	OTHER	MO	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1740265495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-MISSOURI ORTHOTICS & PROSTHETICS

Provider Business Mailing Address
First Line	:	3559 AMAZONAS DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-5717
Country	:	US
Telephone Number	:	573-636-9611
Fax Number	:	573-636-9632

Provider Business Practice Location Address
First Line	:	3559 AMAZONAS DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-5717
Country	:	US
Telephone Number	:	573-636-9611
Fax Number	:	573-636-9632

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	MR. TRACY D ELL
Credential	:
Telephone Number	:	573-636-9611

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	01/19/2012

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Directions to “MID-MISSOURI ORTHOTICS & PROSTHETICS ” Practice Location

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