Basic Information
| Provider Information | |||||||||
| NPI: | 1831348317 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DUKE UNIV MED CTR/AUDIOLOGY | ||||||||
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| OtherOrganizationName: | HEARING AID DISPENSARY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | DUMC BOX 3887 | ||||||||
| Address2: | 160 BAKER HOUSE; TRENT DRIVE | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196843466 | ||||||||
| FaxNumber: | 9196682741 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 BAKER HOUSE; TRENT DRIVE | ||||||||
| Address2: | DUMC BOX 3887 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196843466 | ||||||||
| FaxNumber: | 9196682741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | O'GRADY | ||||||||
| AuthorizedOfficialFirstName: | GWENDOLYN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9196843556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 5001 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3404124 | 05 | NC | MEDICAID |