Basic Information
| Provider Information | |||||||||
| NPI: | 1497811210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRECISION HEARING INSTRUMENTS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIRACLE-EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6514 ODANA RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537191124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088293777 | ||||||||
| FaxNumber: | 6088290430 | ||||||||
| Practice Location | |||||||||
| Address1: | 6514 ODANA RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537191124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088293777 | ||||||||
| FaxNumber: | 6088290430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WISNIEWSKI | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | HEARING INSTRUMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6088293777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | H.I.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 730 - 060 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 42826800 | 05 | WI | MEDICAID | 60Q19MI | 01 | MN | BCBS MN GROUP NUMBER | OTHER |