1306965504 NPI number — DAVID C. WENGER-KELLER, MD

Table of content: (NPI 1306965504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306965504 NPI number — DAVID C. WENGER-KELLER, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID C. WENGER-KELLER, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEAST IOWA FAMILY MEDICINE AND ALLERGY ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306965504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5409 AVENUE O
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
FORT MADISON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52627-9601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-372-6280
Provider Business Mailing Address Fax Number:
319-372-8119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5409 AVENUE O
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FORT MADISON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52627-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-372-6280
Provider Business Practice Location Address Fax Number:
319-372-8119
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WENGER-KELLER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
319-372-6280

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25663 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0790337 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0298828 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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