1760487854 NPI number — PEDIATRIC CENTER, PC

Table of content: (NPI 1760487854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760487854 NPI number — PEDIATRIC CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC CENTER, PC
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:
1760487854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 10TH STREET SE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-363-3600
Provider Business Mailing Address Fax Number:
319-363-9971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 10TH STREET SE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-363-3600
Provider Business Practice Location Address Fax Number:
319-363-9971
Provider Enumeration Date:
06/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCDERMOTT
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER/SHAREHOLDER
Authorized Official Telephone Number:
319-363-3600

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0137885 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2016428 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053173 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1088492 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0171215 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".