Provider Demographics
NPI:1215350251
Name:MIDWEST AUDIOLOGY CENTER, LLC
Entity type:Organization
Organization Name:MIDWEST AUDIOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-281-8300
Mailing Address - Street 1:4818 S 76TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4362
Mailing Address - Country:US
Mailing Address - Phone:414-281-8300
Mailing Address - Fax:414-455-0159
Practice Address - Street 1:4818 S 76TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4362
Practice Address - Country:US
Practice Address - Phone:414-281-8300
Practice Address - Fax:414-455-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152156237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI83991OtherMEDICARE PTAN