Provider Demographics
NPI:1053442491
Name:NORTH SIDE AUDIOLOGY GROUP, INC.
Entity Type:Organization
Organization Name:NORTH SIDE AUDIOLOGY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DARIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:POPOWYCH
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCCA
Authorized Official - Phone:773-777-3277
Mailing Address - Street 1:4200 W. PETERSON AVE.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6052
Mailing Address - Country:US
Mailing Address - Phone:773-777-3277
Mailing Address - Fax:773-777-2878
Practice Address - Street 1:4200 W. PETERSON AVE.
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6052
Practice Address - Country:US
Practice Address - Phone:773-777-3277
Practice Address - Fax:773-777-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000241231H00000X
IL147000271231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL333608331001Medicaid
IL265496573001Medicaid
IL971040Medicare ID - Type Unspecified
IL265496573001Medicaid