Provider Demographics
NPI:1083058721
Name:SYNERGY ORTHOTICS & PROSTHETICS, LLC
Entity type:Organization
Organization Name:SYNERGY ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:EMMANUEL
Authorized Official - Last Name:BASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:703-209-3790
Mailing Address - Street 1:44790 MAYNARD SQ STE 240
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6514
Mailing Address - Country:US
Mailing Address - Phone:571-442-8514
Mailing Address - Fax:571-442-8519
Practice Address - Street 1:44790 MAYNARD SQ STE 240
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6514
Practice Address - Country:US
Practice Address - Phone:571-442-8514
Practice Address - Fax:571-442-8519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACP03073335E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC069832900Medicaid
MD3358399-00Medicaid