1265500383 NPI number — TRACY L EKHARDT M.D.

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 1265500383 NPI number — TRACY L EKHARDT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EKHARDT
Provider First Name:
TRACY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEPHENSON
Provider Other First Name:
TRACY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265500383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 PLEASANT ST
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:
50309-1406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-241-5926
Provider Business Mailing Address Fax Number:
515-241-5127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50309-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-241-5926
Provider Business Practice Location Address Fax Number:
515-241-5127
Provider Enumeration Date:
11/30/2006

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: 2080P0203X , with the licence number:  36820 , 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: 1265500383 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100264995-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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