MEDICARE: DR. MARK BRIAN LITTLE AU D

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	3420	SC
2	231H00000X	Audiologist	AUD003676	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821000514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BRIAN LITTLE AU D

Provider Business Mailing Address
First Line	:	300 W HOSPITAL ROAD
Second Line	:	EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
City	:	FORT GORDON
State	:	GA
Zip	:	30905-5650
Country	:	US
Telephone Number	:	706-787-2720
Fax Number	:	706-787-8176

Provider Business Practice Location Address
First Line	:	300 W HOSPITAL ROAD
Second Line	:	EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
City	:	FORT GORDON
State	:	GA
Zip	:	30905-5650
Country	:	US
Telephone Number	:	706-787-2720
Fax Number	:	706-787-8176

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	05/08/2008

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