1306845094 NPI number — MOBILE MEDICAL DIAGNOSTIC SERVICES

Table of content: (NPI 1306845094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306845094 NPI number — MOBILE MEDICAL DIAGNOSTIC SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOBILE MEDICAL DIAGNOSTIC SERVICES
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:
1306845094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6223 HIGHWAY 63
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTUMWA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52501-8175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-777-1363
Provider Business Mailing Address Fax Number:
641-682-6836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6223 HIGHWAY 63
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTUMWA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52501-8175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-777-1363
Provider Business Practice Location Address Fax Number:
641-682-6836
Provider Enumeration Date:
07/15/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DELKER
Authorized Official First Name:
DARIN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-777-1363

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X , with the licence number:  00419 , 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: 45171 . This is a "WELLMARK BC/BS OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0265850 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 630001464 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".