=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760835938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 N OAK PARK AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60707-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-385-5848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 947109
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30394-7109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-367-2876
-----------------------------------------------------
Fax | 813-518-7659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER, ORTHOTICS AND PROSTHETICS
-----------------------------------------------------
Name | MR. WILLIAM C CRAGGS
-----------------------------------------------------
Credential | CPO, LPO
-----------------------------------------------------
Telephone | 773-466-6922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------