Provider Demographics
NPI:1447378773
Name:PERSONALIZED HEARING CARE
Entity Type:Organization
Organization Name:PERSONALIZED HEARING CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAGACKI
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:734-467-5100
Mailing Address - Street 1:35337 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2013
Mailing Address - Country:US
Mailing Address - Phone:734-467-5100
Mailing Address - Fax:734-467-5103
Practice Address - Street 1:35337 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2013
Practice Address - Country:US
Practice Address - Phone:734-467-5100
Practice Address - Fax:734-467-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000113231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640H227530OtherBLUE CROSS BLUE SHIELD
MI540H104260OtherBLUE CROSS BLUE SHIELD
MI4433772Medicaid
MI0H10426OtherBLUE CARE NETWORK
MI237600000XOtherPROVIDER TAXONOMIES
MI4704347Medicaid
MI0H10426OtherBLUE CARE NETWORK
MI=========OtherTAX ID NUMBER