Basic Information
| Provider Information | |||||||||
| NPI: | 1003962556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOSTON BRACE INTERNATIONAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOSTON ORTHOTICS & PROSTHETICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 LEDIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023221156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002622235 | ||||||||
| FaxNumber: | 5085592750 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
| FaxNumber: | 9082337286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | MORRISSEY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5085886060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 0124892 | 01 | HMO | OTHER | A382634 | 01 | OXFORD | OTHER | 4623401 | 05 | NJ | MEDICAID | 28950 | 01 | UNIVERSITY HEALTH PLAN | OTHER | 8432848 | 01 | NON HMO | OTHER | OL0601 | 01 | HEALTHNET | OTHER |