=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780889329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE S VERSCHAGE AUD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 W 8TH ST UFJAX - OTOLARYNGOLOGY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32209-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-4267
-----------------------------------------------------
Fax | 904-244-7730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 44008 UFJP - PROVIDER ENROLLMENT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32231-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-3199
-----------------------------------------------------
Fax | 904-244-3425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AY1414
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------