Basic Information
| Provider Information | |||||||||
| NPI: | 1811068430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-STATE AUDIOLOGY PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSIOLOGIC ASSESSMENT SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 TEANECK RD | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018629900 | ||||||||
| FaxNumber: | 2018629136 | ||||||||
| Practice Location | |||||||||
| Address1: | 1086 TEANECK RD | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018629900 | ||||||||
| FaxNumber: | 2018629136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DANTO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2018629900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD, D-ABNM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.