Basic Information
Provider Information | |||||||||
NPI: | 1770550196 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARRED | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 153 BLAIR ST | ||||||||
Address2: |   | ||||||||
City: | WHITING | ||||||||
State: | IA | ||||||||
PostalCode: | 510631007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7124552431 | ||||||||
FaxNumber: | 7124552698 | ||||||||
Practice Location | |||||||||
Address1: | 153 BLAIR ST | ||||||||
Address2: |   | ||||||||
City: | WHITING | ||||||||
State: | IA | ||||||||
PostalCode: | 510631007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7124552431 | ||||||||
FaxNumber: | 7124552698 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2006 | ||||||||
LastUpdateDate: | 05/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 23466 | IA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0208728 | 05 | IA |   | MEDICAID | 42101479900 | 05 | NE |   | MEDICAID | 010034591 | 01 |   | RAILROAD MEDICARE | OTHER |