MEDICARE: MARK LAVINE

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	237700000X	Hearing Instrument Specialist	14000007017	NY

General Provider Information

NPI Number	:	1760422059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LAVINE

Provider Business Mailing Address
First Line	:	5000 CHESHIRE LN N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55446-3706
Country	:	US
Telephone Number	:	888-333-9152
Fax Number	:	763-268-4240

Provider Business Practice Location Address
First Line	:	346 N MIDLER AVE
Second Line	:	STE. 38
City	:	SYRACUSE
State	:	NY
Zip	:	13206-2279
Country	:	US
Telephone Number	:	315-437-0325
Fax Number	:	315-432-0958

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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