1336314574 NPI number — IOWA ILLINOIS PAIN CONSULTANTS P.C.

Table of content: (NPI 1336314574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336314574 NPI number — IOWA ILLINOIS PAIN CONSULTANTS P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IOWA ILLINOIS PAIN CONSULTANTS P.C.
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:
1336314574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-424-0512
Provider Business Mailing Address Fax Number:
563-326-6236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3385 DEXTER CT
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52807-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-424-0512
Provider Business Practice Location Address Fax Number:
563-326-6236
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
JON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
563-424-0512

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  26118 , 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: 4024711 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14316 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 036079595 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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