Basic Information
| Provider Information | |||||||||
| NPI: | 1215442827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 SHUMAN BLVD STE 401 | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605638123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHICAGO AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308101340 | ||||||||
| FaxNumber: | 6305980318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 3164 | IL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.