MEDICARE: NORTH SIDE AUDIOLOGY GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	147000271	IL
2	231H00000X	Audiologist	147000241	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053442491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SIDE AUDIOLOGY GROUP, INC.

Provider Business Mailing Address
First Line	:	4200 W. PETERSON AVE.
Second Line	:	SUITE 100
City	:	CHICAGO
State	:	IL
Zip	:	60646-6052
Country	:	US
Telephone Number	:	773-777-3277
Fax Number	:	773-777-2878

Provider Business Practice Location Address
First Line	:	4200 W. PETERSON AVE.
Second Line	:	SUITE 100
City	:	CHICAGO
State	:	IL
Zip	:	60646-6052
Country	:	US
Telephone Number	:	773-777-3277
Fax Number	:	773-777-2878

Authorized Official
Title or Position	:	AUDIOLOGIST
Name	:	MS. DARIA T POPOWYCH
Credential	:	MS CCCA
Telephone Number	:	773-777-3277

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	12/07/2012

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