MEDICARE: DOUGLAS HOLDING GROUP

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	17001443A	IN

General Provider Information

NPI Number	:	1639525942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS HOLDING GROUP

Provider Business Mailing Address
First Line	:	7525 MAPLECREST RD
Second Line	:	SUITE 104
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-1897
Country	:	US
Telephone Number	:	260-749-1818
Fax Number	:

Provider Business Practice Location Address
First Line	:	6424 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7025
Country	:	US
Telephone Number	:	260-749-1818
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. STEVE S DOUGLAS
Credential	:	H.I.S.
Telephone Number	:	260-749-1818

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	05/05/2016

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