1568427524 NPI number — DUBUQUE INTERNAL MEDICINE PC

Table of content: (NPI 1568427524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568427524 NPI number — DUBUQUE INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUBUQUE 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:
GRAND RIVER MEDICAL GROUP, PC
Provider Other Organization Name Type Code:
3
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:
1568427524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 DELHI ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52001-6389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-557-9111
Provider Business Mailing Address Fax Number:
563-589-4063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 DELHI ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
DUBUQUE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52001-6389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-557-9111
Provider Business Practice Location Address Fax Number:
563-589-4063
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAFNER
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
563-557-9111

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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