MEDICARE: BI-STATE 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	8221629	OTHER	IL	BCBS OF IL
2	122758	OTHER	MO	BCBS OF MO

General Provider Information

NPI Number	:	1154462950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BI-STATE ORTHOTICS & PROSTHETICS

Provider Business Mailing Address
First Line	:	12660 LAMPLIGHTER SQR SHPPNG CTR
Second Line	:	SUITE J
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2761
Country	:	US
Telephone Number	:	314-843-2664
Fax Number	:	314-842-3866

Provider Business Practice Location Address
First Line	:	6400 W MAIN ST
Second Line	:	SUITE 3G
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3806
Country	:	US
Telephone Number	:	314-843-2664
Fax Number	:	314-842-3866

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICHAEL J NIEDER
Credential	:	C.O.
Telephone Number	:	314-843-2664

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	06/26/2008

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