MEDICARE: PEYTON PROVOST 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	AT007055	PA

General Provider Information

NPI Number	:	1861385841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEYTON PROVOST AU.D.

Provider Business Mailing Address
First Line	:	4813 W CHESTER PIKE
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-2213
Country	:	US
Telephone Number	:	484-331-9422
Fax Number	:	484-331-9423

Provider Business Practice Location Address
First Line	:	4813 W CHESTER PIKE
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-2213
Country	:	US
Telephone Number	:	215-268-7697
Fax Number	:

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

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	07/22/2025

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