Provider Demographics
NPI:1083697510
Name:HEARING DIAGNOSTICS CENTER PC
Entity Type:Organization
Organization Name:HEARING DIAGNOSTICS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:574-534-4171
Mailing Address - Street 1:1206 COLLEGE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4937
Mailing Address - Country:US
Mailing Address - Phone:574-534-4171
Mailing Address - Fax:574-533-3466
Practice Address - Street 1:1206 COLLEGE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4937
Practice Address - Country:US
Practice Address - Phone:574-534-4171
Practice Address - Fax:574-533-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN58000001A231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0303310002OtherADMINISTAR
000000087117OtherANTHEM BCBS AUDIOLOGY
IN100113470AMedicaid
IN000000201762OtherHA SUPPLIER (DME)
IN100113470AMedicaid
226800Medicare ID - Type Unspecified