1417375221 NPI number — SUSAN LIGHT ROEWE MD

Table of content: SUSAN LIGHT ROEWE MD (NPI 1417375221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417375221 NPI number — SUSAN LIGHT ROEWE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROEWE
Provider First Name:
SUSAN
Provider Middle Name:
LIGHT
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:
LIGHT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
K
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:
1417375221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1690 ELM ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52001-3679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-902-8505
Provider Business Mailing Address Fax Number:
635-578-4885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1690 ELM ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBUQUE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52001-3679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-690-2850
Provider Business Practice Location Address Fax Number:
563-557-8488
Provider Enumeration Date:
03/31/2014

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: 208000000X , with the licence number:  64848-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: MD-46764 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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