Basic Information
| Provider Information | |||||||||
| NPI: | 1922203298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST AUDIOLOGY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 POOLER AVE | ||||||||
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| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601154626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1815751224 | ||||||||
| FaxNumber: | 8157540993 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 N GALENA AVE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610212115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152881111 | ||||||||
| FaxNumber: | 8152881111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FOGEL | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | RAMSEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8152881111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.A., CCC-A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231HA2400X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03803 | 01 | CO | HEARUSA, HEARING CARE NET | OTHER |