1477534279 NPI number — MR. EDMUND J PIASECKI III FNP

Table of content: MR. EDMUND J PIASECKI III FNP (NPI 1477534279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477534279 NPI number — MR. EDMUND J PIASECKI III FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIASECKI III
Provider First Name:
EDMUND
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIASECKI
Provider Other First Name:
ED
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1477534279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2207 WILLOWMERE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50321-1539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-244-4550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 6TH AVE
Provider Second Line Business Practice Location Address:
MERCY MEDICAL CENTE ER
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50314-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-247-3173
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2005

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: 363LF0000X , with the licence number:  A100182 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 2001021075 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 45213 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 425701513 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0463448 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425701505 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".