Provider Demographics
NPI:1073512893
Name:MID WEST HEARING LLC
Entity Type:Organization
Organization Name:MID WEST HEARING LLC
Other - Org Name:MIRACLE EAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEARING INSTRUMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-736-2284
Mailing Address - Street 1:131 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3326
Mailing Address - Country:US
Mailing Address - Phone:401-353-4174
Mailing Address - Fax:518-736-2285
Practice Address - Street 1:2504 3RD AVE N
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1323
Practice Address - Country:US
Practice Address - Phone:906-233-1656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332S00000X
WI1209-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Yes332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42836700Medicaid