1972709046 NPI number — DR. KAREN ANN BRENOT D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972709046 NPI number — DR. KAREN ANN BRENOT D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENOT
Provider First Name:
KAREN
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
KAREN
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972709046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4480 UTICA RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 1140
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-742-5700
Provider Business Mailing Address Fax Number:
563-742-5705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4480 UTICA RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 1140
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-742-5700
Provider Business Practice Location Address Fax Number:
563-742-5705
Provider Enumeration Date:
06/25/2007

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: 207V00000X , with the licence number:  5101016468 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 3956 , 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: 1972709046 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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