Basic Information
| Provider Information | |||||||||
| NPI: | 1871702860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST HEARING CONSULTANTS GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SEARS HEARING AID CENTER,MIRACLE-EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 313 RODDY RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628813836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185480024 | ||||||||
| FaxNumber: | 6185482403 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 SAINT CLAIR SQ | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622082134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186248805 | ||||||||
| FaxNumber: | 6182062318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEATON | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT,CONSULTANT DISPENSER | ||||||||
| AuthorizedOfficialTelephone: | 6185480024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | STATE LICENSED | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2627 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.