MEDICARE: SUSAN MARIE WAITE NBC-HIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332S00000X	Hearing Aid Equipment	3501002419	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	540C802820	OTHER	MI	BLUE CROSS AND BLUE SHIELD OF MICHIGAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164753950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE WAITE NBC-HIS

Provider Business Mailing Address
First Line	:	2404 WILDWOOD AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3927
Country	:	US
Telephone Number	:	517-788-7677
Fax Number	:	517-788-7679

Provider Business Practice Location Address
First Line	:	2404 WILDWOOD AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3927
Country	:	US
Telephone Number	:	517-788-7677
Fax Number	:	517-788-7679

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	01/19/2010

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