MEDICARE: SUSAN MANN AUD CCCA

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	147000803	IL

General Provider Information

NPI Number	:	1407982077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MANN AUD CCCA

Provider Business Mailing Address
First Line	:	1707 CAESAR LN
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-1579
Country	:	US
Telephone Number	:	618-993-0307
Fax Number	:

Provider Business Practice Location Address
First Line	:	3316 PATRIOT CT
Second Line	:
City	:	HERRIN
State	:	IL
Zip	:	62948-3782
Country	:	US
Telephone Number	:	618-993-0307
Fax Number	:	618-993-0807

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	05/21/2008

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