MEDICARE: DR. MARY T CACCAVO PH.D.

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	237600000X	Audiologist-Hearing Aid Fitter	23001132A	IN
2	231H00000X	Audiologist	23001132A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	640004350	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000202141	OTHER	IN	BCBS UAW
2	000000220890	OTHER	IN	BLUE CROSS BLUE SHIELD
3	000000220890	OTHER	IN	FEDERAL BCBS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	000000220882	OTHER	IN	BCBS UAW

General Provider Information

NPI Number	:	1134116031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY T CACCAVO PH.D.

Provider Business Mailing Address
First Line	:	2122 SCOTT ST.
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904
Country	:	US
Telephone Number	:	765-448-6226
Fax Number	:	765-448-9416

Provider Business Practice Location Address
First Line	:	2122 SCOTT ST.
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2932
Country	:	US
Telephone Number	:	765-448-6226
Fax Number	:	765-448-9416

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	06/28/2010

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Directions to “ DR. MARY T CACCAVO PH.D.” Practice Location

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