1053312603 NPI number — DIGESTIVE AND LIVER DISEASE CONSULTANTS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053312603 NPI number — DIGESTIVE AND LIVER DISEASE CONSULTANTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE AND LIVER DISEASE CONSULTANTS, P.C.
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:
1053312603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 NW 114TH ST
Provider Second Line Business Mailing Address:
STE 342
Provider Business Mailing Address City Name:
CLIVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50325-7007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-223-4823
Provider Business Mailing Address Fax Number:
515-223-0482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 NW 114TH ST
Provider Second Line Business Practice Location Address:
STE 342
Provider Business Practice Location Address City Name:
CLIVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50325-7007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-223-4823
Provider Business Practice Location Address Fax Number:
515-223-0482
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RAYL
Authorized Official First Name:
KOREEN
Authorized Official Middle Name:
KAY LEMASTER
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
515-223-4823

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , 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: 0243857 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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