Provider Demographics
NPI:1649216169
Name:MIDWEST AUDIOLOGY, PC
Entity Type:Organization
Organization Name:MIDWEST AUDIOLOGY, PC
Other - Org Name:PROFESSIONAL HEARING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUDIOLOGIST/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:B
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:701-852-6565
Mailing Address - Street 1:1400 37TH AVE. SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3956
Mailing Address - Country:US
Mailing Address - Phone:701-852-6565
Mailing Address - Fax:701-838-9381
Practice Address - Street 1:1400 37TH AVE. SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3956
Practice Address - Country:US
Practice Address - Phone:701-852-6565
Practice Address - Fax:701-838-9381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55188Medicaid
ND55188Medicaid
NDP23218Medicare UPIN
NDN713388Medicare PIN
NDN713413Medicare PIN
NDN713401Medicare PIN
NDN713412Medicare PIN
NDR02188Medicare UPIN