Basic Information
| Provider Information | |||||||||
| NPI: | 1013958941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATTI L ALLY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLY HEARING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 N KNOXVILLE AVE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092820887 | ||||||||
| FaxNumber: | 3092820947 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 N KNOXVILLE AVE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092820887 | ||||||||
| FaxNumber: | 3092820947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALLY | ||||||||
| AuthorizedOfficialFirstName: | PATTI | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | AUDIOLOGIST OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3092820887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 353701941001 | 05 | IL | MEDICAID |