=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831562123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JOEL SHANAHAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2015
-----------------------------------------------------
Last Update Date | 09/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7830 MAIN ST N STE 225
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369-7208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-400-7275
-----------------------------------------------------
Fax | 763-400-7273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 SHUMAN BLVD STE 401
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-8458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-303-5380
-----------------------------------------------------
Fax | 978-313-6824
-----------------------------------------------------
=====================================================
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 | 2726
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------