1588893911 NPI number — GERDTS PODIATRIC LLC

Table of content: (NPI 1588893911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588893911 NPI number — GERDTS PODIATRIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERDTS PODIATRIC LLC
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:
1588893911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACONIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55387-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-442-9770
Provider Business Mailing Address Fax Number:
952-442-3621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 N 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSAGE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50461-1456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-732-6090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GERDTS
Authorized Official First Name:
CORAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-832-7540

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00722 , 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: DQ3207 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com