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NPI Code Detail

MEDICARE: FORT WAYNE AUDIOLOGY CONSULTANTS, LLC

MEDICARE: FORT WAYNE AUDIOLOGY CONSULTANTS, LLC
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
1261QH0700XHearing and Speech Clinic/Center23002551AIN

Other Identifiers

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

General Provider Information

NPI Number : 1104237916
Entity Type Code : Organization
Provider Name (Legal Business Name) : FORT WAYNE AUDIOLOGY CONSULTANTS, LLC
Provider Business Mailing Address
First Line : 4720 E STATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-6923
Country : US
Telephone Number : 260-471-5693
Fax Number : 260-471-4942
Provider Business Practice Location Address
First Line : 4720 E STATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-6923
Country : US
Telephone Number : 260-471-5693
Fax Number : 260-471-4942
Authorized Official
Title or Position : AUDIOLOGIST/OWNER
Name : DR. THOMAS ZACHARY BURKLE
Credential : AUD
Telephone Number : 317-616-8048
Provider Enumeration Date : 05/14/2014
Last Update Date : 04/27/2016

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Directions to “FORT WAYNE AUDIOLOGY CONSULTANTS, LLC ” Practice Location

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