1649297326 NPI number — GREAT RIVER ONCOLOGY, P.C.

Table of content: (NPI 1649297326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649297326 NPI number — GREAT RIVER ONCOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT RIVER ONCOLOGY, 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:
1649297326
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 633
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52655-0633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-753-1220
Provider Business Mailing Address Fax Number:
319-753-5464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 S GEAR AVE
Provider Second Line Business Practice Location Address:
SUITE 152
Provider Business Practice Location Address City Name:
WEST BURLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52655-1691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-753-1220
Provider Business Practice Location Address Fax Number:
319-753-5464
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REGANTI
Authorized Official First Name:
ROHINI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
319-753-1220

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0274860 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08894 . This is a "BCBS GROUP PROVIDER NUMBE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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