1487731402 NPI number — PRACTICE OF FAMILY MEDICINE, P.C.

Table of content: (NPI 1487731402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487731402 NPI number — PRACTICE OF FAMILY MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTICE OF FAMILY MEDICINE, 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:
1487731402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 42ND ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52402-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-395-7878
Provider Business Mailing Address Fax Number:
319-395-7898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 42ND ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52402-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-395-7878
Provider Business Practice Location Address Fax Number:
319-395-7898
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOUVAR
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
DARRELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
319-395-7878

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01483 , 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: 1487731402 . This is a "MEDICARE B" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 49757 . This is a "BLUE CROSS BLUE SHIELD IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 12493 . This is a "MIDLANDS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 5336687 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 179301 . This is a "JOHN DEERE HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0400454 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A00808 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com