Basic Information
| Provider Information | |||||||||
| NPI: | 1306948617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | B & P HEARING AID CO. INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEARING CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 W HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186246485 | ||||||||
| FaxNumber: | 6186246702 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 W HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186246485 | ||||||||
| FaxNumber: | 6186246702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETTY | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | HEARING INSTRUMENT SPECIALIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6184661227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | HIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 2748 | IL | X | Suppliers | Hearing Aid Equipment | 332S00000X | 2757 | IL | X | Suppliers | Hearing Aid Equipment | 332B00000X | IL | X | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 06032080 | 01 | IL | BCBS PROVIDER NUMBER | OTHER | 1025090 | 01 | IL | ACM PROVIDER NUMBER | OTHER | 271406 | 01 | IL | GHP PROVIDER NUMBER | OTHER | 612129 | 01 | IL | HEALTHLINK PROVIDER NUMBE | OTHER | 271406 | 01 | IL | ADVANTRA PROVIDER NUMBER | OTHER | 364532843001 | 05 | IL | MEDICAID |