Basic Information
| Provider Information | |||||||||
| NPI: | 1770710980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERSBERGEN | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRIEDEL | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
| FaxNumber: | 6414283059 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 6TH AVE SO | ||||||||
| Address2: | |||||||||
| City: | CLEAR LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504282606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413572191 | ||||||||
| FaxNumber: | 6413576020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2009 | ||||||||
| LastUpdateDate: | 05/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS14053 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04277 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4277 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.