=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023322120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEENS AUDIOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2010
-----------------------------------------------------
Last Update Date | 02/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3016 30TH DR 4TH FLOOR
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-1874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-728-7800
-----------------------------------------------------
Fax | 718-728-7803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 30TH DR 4TH FLOOR
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11102-1874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-728-7800
-----------------------------------------------------
Fax | 718-728-7803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOANNA ROUFOS
-----------------------------------------------------
Credential | AUD
-----------------------------------------------------
Telephone | 718-728-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 14000022298
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 001479-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------