=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003816752
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOSEPH STURMAK CCC-A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 SUNSET DR
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-963-8643
-----------------------------------------------------
Fax | 208-489-4075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1345
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-939-1643
-----------------------------------------------------
Fax | 208-489-4075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 20833
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------