MEDICARE: PEDORTHIC SERVICES, LLC

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	332BC3200X	Customized Equipment (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	5939230001	OTHER	KY	MEDICARE DME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000519294	OTHER	KY	ANTHEM BC/BS
2	5574649	OTHER	KY	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	74928	OTHER	KY	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1992818009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDORTHIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	371 SOUTHLAND DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1824
Country	:	US
Telephone Number	:	859-266-0420
Fax Number	:	859-266-0667

Provider Business Practice Location Address
First Line	:	371 SOUTHLAND DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1824
Country	:	US
Telephone Number	:	859-266-0420
Fax Number	:	859-266-0667

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LARRY WHEELER
Credential	:	C.PED
Telephone Number	:	859-266-0420

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/27/2020

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Directions to “PEDORTHIC SERVICES, LLC ” Practice Location

Language	Start Address	Practice Location

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