Provider Demographics
NPI:1720139967
Name:GREGORY J MAAG, MA-CCCA MID AMERICA AUDIOLOGY GROUP, LTD
Entity Type:Organization
Organization Name:GREGORY J MAAG, MA-CCCA MID AMERICA AUDIOLOGY GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAAG
Authorized Official - Suffix:
Authorized Official - Credentials:MA-CCCA
Authorized Official - Phone:618-462-7900
Mailing Address - Street 1:1417 WASHINGTON AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3964
Mailing Address - Country:US
Mailing Address - Phone:618-462-7900
Mailing Address - Fax:
Practice Address - Street 1:1417 WASHINGTON AVE
Practice Address - Street 2:STE 2
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3964
Practice Address - Country:US
Practice Address - Phone:618-462-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL357528445001Medicaid
IL760570Medicare PIN