1639397227 NPI number — DONNA J SIVERTSEN RD, LDN, CDE

Table of content: DONNA J SIVERTSEN RD, LDN, CDE (NPI 1639397227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639397227 NPI number — DONNA J SIVERTSEN RD, LDN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIVERTSEN
Provider First Name:
DONNA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN, CDE
Provider Gender Code:
F

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:
1639397227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK ISLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61201-5351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-779-3200
Provider Business Mailing Address Fax Number:
309-779-2755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 JOHN DEERE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-6892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-779-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2007

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: 133V00000X , with the licence number:  164003533 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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