Healthcare Provider Details

I. General information

NPI: 1194908301
Provider Name (Legal Business Name): BRIAN WAISHWELL M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W COLLEGE DR
PALOS HEIGHTS IL
60463-1775
US

IV. Provider business mailing address

6600 W COLLEGE DR
PALOS HEIGHTS IL
60463-1775
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-3090
  • Fax: 708-371-1529
Mailing address:
  • Phone: 708-371-3090
  • Fax: 708-371-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number147-00820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: