Basic Information
| Provider Information | |||||||||
| NPI: | 1366802274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1343A MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973511100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038383001 | ||||||||
| FaxNumber: | 5038380994 | ||||||||
| Practice Location | |||||||||
| Address1: | 2296 NW KINGS BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417572500 | ||||||||
| FaxNumber: | 5417573001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | EVAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5417572500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD, AUD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 30205 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 229575 | 05 | OR | MEDICAID |