1528224664 NPI number — PHYSICAL MEDICINE & REHABILITATION ASSOCIATES OF NORTHEAST IOWA, INC

Table of content: (NPI 1528224664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528224664 NPI number — PHYSICAL MEDICINE & REHABILITATION ASSOCIATES OF NORTHEAST IOWA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL MEDICINE & REHABILITATION ASSOCIATES OF NORTHEAST IOWA, INC
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:
Provider Other Organization Name Type Code:
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:
1528224664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 238
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50704-0238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-234-0109
Provider Business Mailing Address Fax Number:
319-234-5774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1026 A AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-369-7211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MANSHASI
Authorized Official First Name:
FARID
Authorized Official Middle Name:
FREDERIK
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
319-234-0109

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  27493 , 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: IB1110 . This is a "MEDICARE GROUP IB1110" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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