MEDICARE: JENNIFER G GIST MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	33452	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IA0132	OTHER		JOHN DEERE HEALTH PLAN
2	059729	OTHER		HEALTH ALLIANCE
3	152589	OTHER		IOWA HEALTH SOLUTIONS
4	29717	OTHER	IA	WELLMARK BC/BS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306841168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER G GIST MD

Provider Business Mailing Address
First Line	:	865 LINCOLN RD
Second Line	:	STE L10
City	:	BETTENDORF
State	:	IA
Zip	:	52722-4159
Country	:	US
Telephone Number	:	563-355-9191
Fax Number	:	563-355-3419

Provider Business Practice Location Address
First Line	:	865 LINCOLN RD
Second Line	:	STE 200
City	:	BETTENDORF
State	:	IA
Zip	:	52722-4159
Country	:	US
Telephone Number	:	563-344-8600
Fax Number	:	563-344-2967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	07/09/2007

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Directions to “ JENNIFER G GIST MD” Practice Location

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