Basic Information
| Provider Information | |||||||||
| NPI: | 1184602013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | RODNEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 E 56TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633832667 | ||||||||
| FaxNumber: | 5633832672 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 E 56TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633832667 | ||||||||
| FaxNumber: | 5633832672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 33943 | IA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1244830 | 05 | IA | MEDICAID | IA0113 | 01 | JOHN DEERE HEALTHCARE | OTHER | 130024939 | 01 | RAILROAD MEDICARE | OTHER | 1874249 | 01 | UNITED HEALTHCARE | OTHER | 44939 | 01 | WELLMARK | OTHER |