MEDICARE: WHITESIDE ORTHOTIC AND PROSTHETIC GROUP, INC.

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	LO-151	OH

General Provider Information

NPI Number	:	1255676342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITESIDE ORTHOTIC AND PROSTHETIC GROUP, INC.

Provider Business Mailing Address
First Line	:	3267 OLDE WINTER TRL
Second Line	:
City	:	POLAND
State	:	OH
Zip	:	44514-2893
Country	:	US
Telephone Number	:	330-360-0900
Fax Number	:

Provider Business Practice Location Address
First Line	:	8571 FOXWOOD CT
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44514-4313
Country	:	US
Telephone Number	:	330-360-0900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT / CLINICAL DIRECTOR
Name	:	MR. JOSEPH WILLIAM WHITESIDE
Credential	:	C.O.
Telephone Number	:	330-360-0900

Provider Enumeration Date	:	11/30/2012
Last Update Date	:	11/30/2012

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