Healthcare Provider Details

I. General information

NPI: 1275556532
Provider Name (Legal Business Name): PARTNERS IN PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 GLASS RD NE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

4205 GLASS RD NE
CEDAR RAPIDS IA
52402
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-0110
  • Fax: 319-393-0184
Mailing address:
  • Phone: 319-393-0110
  • Fax: 319-393-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30559
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30509
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1123166
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier24222
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK
# 3
Identifier2123158
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 4
Identifier24232
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name: DENISE M CLARK
Title or Position: PHYSICIAN PRESIDENT
Credential: MD
Phone: 319-393-0110