Basic Information
| Provider Information | |||||||||
| NPI: | 1275556532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARTNERS IN PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 GLASS RD NE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193930110 | ||||||||
| FaxNumber: | 3193930184 | ||||||||
| Practice Location | |||||||||
| Address1: | 4205 GLASS RD NE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193930110 | ||||||||
| FaxNumber: | 3193930184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3193930110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 30559 | IA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 30509 | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1123166 | 05 | IA | MEDICAID | 24222 | 01 | IA | WELLMARK | OTHER | 2123158 | 05 | IA | MEDICAID | 24232 | 01 | IA | WELLMARK | OTHER |