MEDICARE: LIBERTY HEARING CENTER

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	231HA2500X	Assistive Technology Supplier Audiologist	0016191	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0016191	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1104180389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY HEARING CENTER

Provider Business Mailing Address
First Line	:	2204 VOORHIES AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2820
Country	:	US
Telephone Number	:	718-270-3976
Fax Number	:	718-504-4172

Provider Business Practice Location Address
First Line	:	2204 VOORHIES AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2820
Country	:	US
Telephone Number	:	718-270-3976
Fax Number	:	718-504-4172

Authorized Official
Title or Position	:	AUDIOLOGIST
Name	:	DR. JOHN P WEIGAND
Credential	:	AUD
Telephone Number	:	718-270-3976

Provider Enumeration Date	:	07/02/2012
Last Update Date	:	07/02/2012

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