MEDICARE: IRENA RENATA RDZANEK

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	237600000X	Audiologist-Hearing Aid Fitter	AY77	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J0594	OTHER	FL	BLUE CROSS BLUE SHIELD
2	S0792	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1437154218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENA RENATA RDZANEK

Provider Business Mailing Address
First Line	:	190 ESTRELLITA DR
Second Line	:
City	:	FT MYERS BEACH
State	:	FL
Zip	:	33931-5204
Country	:	US
Telephone Number	:	239-463-7149
Fax Number	:	239-463-7149

Provider Business Practice Location Address
First Line	:	5600 TRAIL BLVD
Second Line	:	STE 16
City	:	NAPLES
State	:	FL
Zip	:	34108-2860
Country	:	US
Telephone Number	:	239-566-2727
Fax Number	:	239-463-7149

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	07/08/2007

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