MEDICARE: MALCOM DANIEL KIRTLEY 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	2016029074	MO

General Provider Information

NPI Number	:	1417462540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALCOM DANIEL KIRTLEY 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	:	2705 N KANSAS EXPY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-1113
Country	:	US
Telephone Number	:	417-865-8882
Fax Number	:	417-865-7994

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

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	03/17/2018

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