MEDICARE: SP ORTHOTIC SURGICAL & MEDICAL SUPPLY,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	332B00000X	Durable Medical Equipment & Medical Supplies	1189863	NY

General Provider Information

NPI Number	:	1366551376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SP ORTHOTIC SURGICAL & MEDICAL SUPPLY,INC

Provider Business Mailing Address
First Line	:	2946 AVE S
Second Line	:	SP ORTHOTIC SURGICAL & MEDICAL SUPPLY, INC
City	:	BROOKLYN
State	:	NY
Zip	:	11229
Country	:	US
Telephone Number	:	718-627-3305
Fax Number	:	718-627-3307

Provider Business Practice Location Address
First Line	:	2946 AVENUE S
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3229
Country	:	US
Telephone Number	:	718-627-3305
Fax Number	:	718-627-3307

Authorized Official
Title or Position	:	OWNER
Name	:	GRIGORIY SPIVAK
Credential	:
Telephone Number	:	718-627-3305

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/05/2008

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