1326095399 NPI number — LON RUSSELL BREWER D.O.

Table of content: LON RUSSELL BREWER D.O. (NPI 1326095399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326095399 NPI number — LON RUSSELL BREWER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
LON
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1326095399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2014
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:
1924 NW 88TH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50325-5463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-237-3974
Provider Business Practice Location Address Fax Number:
515-883-2692
Provider Enumeration Date:
05/27/2006

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: 207Q00000X , with the licence number:  01444 , 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: 1326095399 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5084277 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080171037 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1326095399 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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