1306841168 NPI number — JENNIFER G GIST MD

Table of content: JENNIFER G GIST MD (NPI 1306841168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306841168 NPI number — JENNIFER G GIST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIST
Provider First Name:
JENNIFER
Provider Middle Name:
G
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:
CARR
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
G
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:
1306841168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
865 LINCOLN RD
Provider Second Line Business Mailing Address:
STE L10
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-4159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-355-9191
Provider Business Mailing Address Fax Number:
563-355-3419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
865 LINCOLN RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-344-8600
Provider Business Practice Location Address Fax Number:
563-344-2967
Provider Enumeration Date:
06/17/2005

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:  33452 , 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: IA0132 . This is a "JOHN DEERE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 059729 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 152589 . This is a "IOWA HEALTH SOLUTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 29717 . This is a "WELLMARK BC/BS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1207886 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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