MEDICARE: MICHAEL A DEROSA HIS

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	237700000X	Hearing Instrument Specialist	3164	IL

General Provider Information

NPI Number	:	1215442827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL A DEROSA HIS

Provider Business Mailing Address
First Line	:	215 SHUMAN BLVD STE 401
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-8123
Country	:	US
Telephone Number	:	630-303-5380
Fax Number	:	630-303-5385

Provider Business Practice Location Address
First Line	:	200 E CHICAGO AVE STE 102
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-1756
Country	:	US
Telephone Number	:	630-810-1340
Fax Number	:	630-598-0318

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

Provider Enumeration Date	:	12/05/2017
Last Update Date	:	07/23/2019

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