MEDICARE: MEDSOURCE ORTHOTICS & PROSTHETICS, 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

General Provider Information

NPI Number	:	1386786614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDSOURCE ORTHOTICS & PROSTHETICS, INC

Provider Business Mailing Address
First Line	:	3636 N 3RD AVE
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85013-3904
Country	:	US
Telephone Number	:	602-395-3354
Fax Number	:	602-395-3361

Provider Business Practice Location Address
First Line	:	3636 N 3RD AVE
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85013-3904
Country	:	US
Telephone Number	:	602-395-3354
Fax Number	:	602-395-3361

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID CHARLES
Credential	:
Telephone Number	:	801-890-6824

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	09/14/2018

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