MEDICARE: DR. TINA SAMPLE AUD

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	A. 01352	OH

General Provider Information

NPI Number	:	1871879890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA SAMPLE AUD

Provider Business Mailing Address
First Line	:	3085 W MARKET ST STE 102
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-3620
Country	:	US
Telephone Number	:	330-379-9070
Fax Number	:	330-379-2358

Provider Business Practice Location Address
First Line	:	3085 W MARKET ST STE 102
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-3620
Country	:	US
Telephone Number	:	330-379-9070
Fax Number	:	330-379-2358

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

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	01/31/2026

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