=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558443002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND HEARING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7710 MERCY RD BERGAN PROFESSIONAL CENTER NORTH, SUITE 322
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68124-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-932-1999
-----------------------------------------------------
Fax | 402-932-1948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7710 MERCY RD BERGAN PROFESSIONAL CENTER NORTH, SUITE 322
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68124-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-932-1999
-----------------------------------------------------
Fax | 402-932-1948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK DOUGLAS FREY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 402-932-1999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 21783
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------