Healthcare Provider Details

I. General information

NPI: 1396089975
Provider Name (Legal Business Name): NORTHWESTERN UNIVERSITY AUDIOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 CAMPUS DR
EVANSTON IL
60208-3550
US

IV. Provider business mailing address

2240 CAMPUS DR
EVANSTON IL
60208-3550
US

V. Phone/Fax

Practice location:
  • Phone: 847-491-3165
  • Fax: 847-467-0410
Mailing address:
  • Phone: 847-491-3165
  • Fax: 847-467-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2355A2700X
TaxonomyAudiology Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name: PROF. SUMITRAJIT DHAR
Title or Position: ASSOCIATE CHAIR
Credential: PHD
Phone: 847-491-2470