Active NPI
Eliza S. Petersen, AUD, CCCA
- Audiologist
- Driggs, ID
National Provider Identifier
1083750996
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Audiologist
- License
- AUD-1142
- Practice address
- 2740 Shadowmoon LN Ste 417
Driggs, ID 83422-5083 - Phone
- (307) 745-5587
- Fax
- (877) 515-1633
- NPI assigned
- Jan 29, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Audiologist | 231H00000X | A-974 | WY | |
| Audiologist | 231H00000X | AUD-1142 | ID | Primary |
Addresses
Primary practice location
2740 Shadowmoon LN Ste 417
Driggs, ID 83422-5083
Mailing address
1388 Mount Moriah Rd
Livermore, CO 80536-9311
Phone (307) 745-5587
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 807694600 | Medicaid | ID | |
| 125563100 | Medicaid | WY |
Other names 1
- Eliza Schwab
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Master of Arts
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AUD-1142 | ID | MD | Audiologist |
| A-974 | WY | MD | Audiologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Rudden Audiology, Inc. | Audiologist | Past | Accepting new patients |
| Teton Hearing Center LLC | Audiologist | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Audiologist
- Driggs, ID
- NPI 1659523694
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170028800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1681862400000",
"number": "1083750996",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1388 MOUNT MORIAH RD",
"city": "LIVERMORE",
"state": "CO",
"postal_code": "805369311",
"telephone_number": "307-745-5587",
"fax_number": "877-515-1633"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2740 SHADOWMOON LN STE 417",
"city": "DRIGGS",
"state": "ID",
"postal_code": "834225083",
"telephone_number": "307-745-5587",
"fax_number": "877-515-1633"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "ELIZA",
"middle_name": "S.",
"name_prefix": "Dr.",
"credential": "AUD, CCCA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-01-29",
"last_updated": "2023-04-19",
"certification_date": "2023-04-19",
"status": "A"
},
"taxonomies": [
{
"code": "231H00000X",
"taxonomy_group": "",
"desc": "Audiologist",
"state": "WY",
"license": "A-974",
"primary": false
},
{
"code": "231H00000X",
"taxonomy_group": "",
"desc": "Audiologist",
"state": "ID",
"license": "AUD-1142",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "807694600",
"state": "ID"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "125563100",
"state": "WY"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "ELIZA",
"last_name": "SCHWAB",
"credential": "MA, CCCA, FAAA",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Driggs, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.