Basic Information
| Provider Information | |||||||||
| NPI: | 1760487854 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 10TH STREET SE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193633600 | ||||||||
| FaxNumber: | 3193639971 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 10TH STREET SE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193633600 | ||||||||
| FaxNumber: | 3193639971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCDERMOTT | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 3193633600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0137885 | 05 | IA | MEDICAID | 2016428 | 05 | IA | MEDICAID | 1053173 | 05 | IA | MEDICAID | 1088492 | 05 | IA | MEDICAID | 0171215 | 05 | IA | MEDICAID |