Provider Demographics
NPI:1497119887
Name:MIDWEST DYSPHAGIA DIAGNOSTICS PC
Entity Type:Organization
Organization Name:MIDWEST DYSPHAGIA DIAGNOSTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCC-SLP
Authorized Official - Phone:816-986-0361
Mailing Address - Street 1:1375 SW 100TH RD
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MO
Mailing Address - Zip Code:64040-8440
Mailing Address - Country:US
Mailing Address - Phone:816-986-0361
Mailing Address - Fax:816-817-0922
Practice Address - Street 1:1375 SW 100TH RD
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MO
Practice Address - Zip Code:64040-8440
Practice Address - Country:US
Practice Address - Phone:816-986-0361
Practice Address - Fax:816-817-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012041520235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA4003OtherMEDICARE PTAN
MOMA6285OtherMEDICARE PTAN