MEDICARE: DR. ELLY E. POURASEF AUD, CCC/A

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	80074	TX
2	237600000X	Audiologist-Hearing Aid Fitter	80074	TX

General Provider Information

NPI Number	:	1396916706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLY E. POURASEF AUD, CCC/A

Provider Business Mailing Address
First Line	:	9071 SOUTH 1300 WEST
Second Line	:	SUITE 100
City	:	WEST JORDAN
State	:	UT
Zip	:	84088
Country	:	US
Telephone Number	:	801-938-1117
Fax Number	:	801-938-2771

Provider Business Practice Location Address
First Line	:	908 TOWN AND COUNTRY BLVD.
Second Line	:	SUITE 120
City	:	HOUSTON
State	:	TX
Zip	:	77024-2208
Country	:	US
Telephone Number	:	713-984-7562
Fax Number	:	866-961-3161

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

Provider Enumeration Date	:	03/13/2008
Last Update Date	:	04/29/2011

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