Provider Demographics
NPI:1689700338
Name:MCSHANE, MARK R (AUD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MCSHANE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:215 SHUMAN BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8458
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:
Practice Address - Street 1:1111 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5317
Practice Address - Country:US
Practice Address - Phone:269-324-0301
Practice Address - Fax:269-324-2387
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI64OC91290OtherBLUE CROSS AUDIOLOGY
MI804836453Medicaid
MI64OC91290OtherBLUE CROSS AUDIOLOGY