Basic Information
| Provider Information | |||||||||
| NPI: | 1780281915 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT PHYSICIAN GROUP, IOWA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
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| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789675599 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 HEARTLAND DR | ||||||||
| Address2: | |||||||||
| City: | CORALVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522412733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3196454001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6789675599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.