1891862033 NPI number — HEARTLAND DERMATOLGY & SKIN CANCER CENTER PC

Table of content: (NPI 1891862033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891862033 NPI number — HEARTLAND DERMATOLGY & SKIN CANCER CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND DERMATOLGY & SKIN CANCER CENTER PC
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:
1891862033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12327 STRATFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLIVE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50325-8148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-224-7088
Provider Business Mailing Address Fax Number:
515-224-9228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12327 STRATFORD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50325-8148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-224-7088
Provider Business Practice Location Address Fax Number:
515-224-9228
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELDMAN
Authorized Official First Name:
AVA
Authorized Official Middle Name:
RISA
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
515-224-7088

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CN3179 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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