1871645663 NPI number — TANYA BRUSTER TEGGATZ MD

Table of content: TANYA BRUSTER TEGGATZ MD (NPI 1871645663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871645663 NPI number — TANYA BRUSTER TEGGATZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEGGATZ
Provider First Name:
TANYA
Provider Middle Name:
BRUSTER
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:
BRUSTER
Provider Other First Name:
TANYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871645663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 FOUNTAINS DR. N.E. STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-393-4307
Provider Business Mailing Address Fax Number:
319-294-6912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5264 COUNCIL ST NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-221-8444
Provider Business Practice Location Address Fax Number:
319-221-8589
Provider Enumeration Date:
01/18/2007

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: 207Q00000X , with the licence number:  32590 , 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: 4154062 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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