1386886257 NPI number — RACHAEL RICKERTSEN DIRKSEN MD

Table of content: RACHAEL RICKERTSEN DIRKSEN MD (NPI 1386886257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386886257 NPI number — RACHAEL RICKERTSEN DIRKSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIRKSEN
Provider First Name:
RACHAEL
Provider Middle Name:
RICKERTSEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICKERTSEN
Provider Other First Name:
RACHAEL
Provider Other Middle Name:
RAELYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386886257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 E 9TH ST
Provider Second Line Business Mailing Address:
UIHC IRL, INTERNAL MEDICINE
Provider Business Mailing Address City Name:
CORALVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52241-2209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-467-2000
Provider Business Mailing Address Fax Number:
319-467-2512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 E 9TH ST
Provider Second Line Business Practice Location Address:
UIHC IRL, INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-467-2000
Provider Business Practice Location Address Fax Number:
319-467-2512
Provider Enumeration Date:
03/24/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 40261 , 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)