1851592018 NPI number — DR. RONALD BENJAMIN COLLINS JR. M.D.

Table of content: XIYA LIU (NPI 1407744113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851592018 NPI number — DR. RONALD BENJAMIN COLLINS JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
RONALD
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1851592018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRINNELL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50112-1898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRINNELL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50112-1898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-236-2382
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2007

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: 207R00000X , with the licence number:  125050346 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 39422 , 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: CA4079 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036119753 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 809840 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00617107 . This is a "RR MEDICARE MEMBER PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1669420501 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: I17380 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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