MEDICARE: PATRIOT ORTHOTIC PRODUCTS 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)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8200611	OTHER	MA	UNITEDHEALTHCARE DME PROV

General Provider Information

NPI Number	:	1245278811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRIOT ORTHOTIC PRODUCTS LLC

Provider Business Mailing Address
First Line	:	790 TURNPIKE ST
Second Line	:	SUITE 202
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-6144
Country	:	US
Telephone Number	:	978-794-5528
Fax Number	:	978-794-5529

Provider Business Practice Location Address
First Line	:	790 TURNPIKE ST
Second Line	:	SUITE 202
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-6144
Country	:	US
Telephone Number	:	978-794-5528
Fax Number	:	978-794-5529

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	SUSAN D RAYMOND
Credential	:	PT, CPED
Telephone Number	:	978-794-5528

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/22/2020

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