1356521504 NPI number — SOUTHEAST IOWA ORTHOPEDICS & SPORTS MEDICINE PC

Table of content: (NPI 1356521504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356521504 NPI number — SOUTHEAST IOWA ORTHOPEDICS & SPORTS MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST IOWA ORTHOPEDICS & SPORTS MEDICINE 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:
1356521504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52601-0156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-758-9133
Provider Business Mailing Address Fax Number:
319-758-9143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52601-4608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-758-9133
Provider Business Practice Location Address Fax Number:
319-758-9143
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
319-758-9133

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  26178 , 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: 10954 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 30001 . This is a "IAHS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 470000991 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 267960871 . This is a "MEDICAID ILLINOIS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1043539 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46204 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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