=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861548893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN PHILLIPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4723 HIAWATHA AVE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55406-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-721-6338
-----------------------------------------------------
Fax | 612-729-8378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 CHESHIRE LN N
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55446-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-268-4169
-----------------------------------------------------
Fax | 763-268-4240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 5659
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------