Basic Information
Provider Information | |||||||||
NPI: | 1740494244 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLENDORF ENT, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 766 | ||||||||
Address2: |   | ||||||||
City: | CARROLL | ||||||||
State: | IA | ||||||||
PostalCode: | 514010766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7127924368 | ||||||||
FaxNumber: | 7127924351 | ||||||||
Practice Location | |||||||||
Address1: | 405 S CLARK ST | ||||||||
Address2: | SUITE 215 | ||||||||
City: | CARROLL | ||||||||
State: | IA | ||||||||
PostalCode: | 514013065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7127924368 | ||||||||
FaxNumber: | 7127922056 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 03/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLENDORF | ||||||||
AuthorizedOfficialFirstName: | TRACEY | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7127924368 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 30594 | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 2124032 | 05 | IA |   | MEDICAID | 1124032 | 05 | IA |   | MEDICAID | 5124032 | 05 | IA |   | MEDICAID | 3124032 | 05 | IA |   | MEDICAID | 6124032 | 05 | IA |   | MEDICAID |