1114974961 NPI number — DES MOINES INTERNAL MEDICINE PC

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 1114974961 NPI number — DES MOINES INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DES MOINES INTERNAL MEDICINE 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:
1114974961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 WALNUT ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50309-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-243-1180
Provider Business Mailing Address Fax Number:
515-243-1461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 WALNUT ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50309-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-243-1180
Provider Business Practice Location Address Fax Number:
515-243-1461
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRIER
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
515-243-1180

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  02396 , 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: 0476184 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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