Basic Information
| Provider Information | |||||||||
| NPI: | 1720257124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUCKLOW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950116 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133884 | ||||||||
| Practice Location | |||||||||
| Address1: | 2125 STATE ST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129453557 | ||||||||
| FaxNumber: | 8122061784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2008 | ||||||||
| LastUpdateDate: | 05/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0520 | KY | N | Other Service Providers | Specialist | 207Y00000X | 0520 | KY | N | Allopathic & Osteopathic Physicians | Otolaryngology | 231H00000X | 23002305A | IN | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 200937310 | 05 | IN | MEDICAID |