1104870690 NPI number — DIAGNOSTIC & INT MED ASSOC PC

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 1104870690 NPI number — DIAGNOSTIC & INT MED ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAGNOSTIC & INT MED ASSOC 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:
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:
1104870690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 RIDGE ST
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-4643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-322-5532
Provider Business Mailing Address Fax Number:
800-293-4214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 RIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-5532
Provider Business Practice Location Address Fax Number:
800-293-4214
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRICSFELD
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
712-322-5532

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0129437 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CP8208 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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