=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548089204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY MASSARELLA BC- H.I.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 VETERANS MEMORIAL PKWY STE 201
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-853-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1835 SULLIVAN POINTE DR
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-853-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2021004907
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------