=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548546807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH SHORE HEARING, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2011
-----------------------------------------------------
Last Update Date | 10/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 SHERWOOD DR
-----------------------------------------------------
City | SHOREHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11786-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-764-3017
-----------------------------------------------------
Fax | 631-425-4670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 SHERWOOD DR
-----------------------------------------------------
City | SHOREHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11786-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-764-3017
-----------------------------------------------------
Fax | 631-425-4670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUDIOLOGIST
-----------------------------------------------------
Name | MRS. DIANE FAULKNOR
-----------------------------------------------------
Credential | M.A., CCC/A
-----------------------------------------------------
Telephone | 631-403-4885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 00-1371
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------