Basic Information
| Provider Information | |||||||||
| NPI: | 1881691517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOTIADIS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 827 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502131666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413422128 | ||||||||
| FaxNumber: | 6413423179 | ||||||||
| Practice Location | |||||||||
| Address1: | 827 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502131666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413422128 | ||||||||
| FaxNumber: | 6413423179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 05/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24337 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1024422 | 05 | IA | MEDICAID | 1881691517 | 05 | IA | MEDICAID | 080063418 | 01 | IA | RR MEDICARE | OTHER |