Basic Information
| Provider Information | |||||||||
| NPI: | 1558446468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOOMSBURG UNIVERSITY SPEECH & HEARING CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E. 2ND STREET | ||||||||
| Address2: | CENTENNIAL HALL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703895380 | ||||||||
| FaxNumber: | 5703895022 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E 2ND ST | ||||||||
| Address2: | CENTENNIAL HALL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703895380 | ||||||||
| FaxNumber: | 5703895022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | ANGELO | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5703895380 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 237600000X | D00617 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231HA2500X | D00617 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Supplier | 231HA2400X | D00617 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner | 231H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 50218 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 50009520 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 0019428910003 | 05 | PA | MEDICAID | 0019428910002 | 05 | PA | MEDICAID |