=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104179126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD J PATUSH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2012
-----------------------------------------------------
Last Update Date | 10/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4950 N CUMBERLAND AVE
-----------------------------------------------------
City | NORRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60706-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-456-2930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 597 N YORK ST
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-833-8382
-----------------------------------------------------
Fax | 630-833-8158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 1216
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------