MEDICARE: SUNCOAST AUDIOLOGY, LLC

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	261QH0700X	Hearing and Speech Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AY906	OTHER	FL	FLORIDA STATE LICENSE

General Provider Information

NPI Number	:	1871141671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNCOAST AUDIOLOGY, LLC

Provider Business Mailing Address
First Line	:	11200 SEMINOLE BLVD STE 301
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33778-3240
Country	:	US
Telephone Number	:	727-977-5222
Fax Number	:

Provider Business Practice Location Address
First Line	:	11200 SEMINOLE BLVD STE 301
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33778-3240
Country	:	US
Telephone Number	:	727-977-5222
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KELLY J DYSON
Credential	:	AU.D.
Telephone Number	:	727-977-5222

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	08/27/2019

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