Basic Information
| Provider Information | |||||||||
| NPI: | 1417263609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHONEY | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 CHESHIRE PKWY N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554464103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885100766 | ||||||||
| FaxNumber: | 7632684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N CLIPPERT ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489124694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173221691 | ||||||||
| FaxNumber: | 5173240210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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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 | 231H00000X | 1601000561 | MI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 640E801070 | 01 | MI | BCBS | OTHER |