1154375731 NPI number — JAMESON ORTHOPEDIC CLINIC PC

Table of content: (NPI 1154375731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154375731 NPI number — JAMESON ORTHOPEDIC CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMESON ORTHOPEDIC CLINIC 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:
1154375731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 GRAND AVE
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:
50312-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-237-3974
Provider Business Mailing Address Fax Number:
515-883-2692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 S GEAR AVE
Provider Second Line Business Practice Location Address:
SUITE 159
Provider Business Practice Location Address City Name:
WEST BURLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52655-1691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-752-4553
Provider Business Practice Location Address Fax Number:
319-753-0462
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JAMESON
Authorized Official First Name:
THERON
Authorized Official Middle Name:
QUENTIN
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
319-752-4553

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0462325 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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