Healthcare Provider Details

I. General information

NPI: 1841355104
Provider Name (Legal Business Name): KATHLEEN OPDEBEECK MACMENAMIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 A AVE NE
CEDAR RAPIDS IA
52402-5036
US

IV. Provider business mailing address

PO BOX 9306
DES MOINES IA
50306-9306
US

V. Phone/Fax

Practice location:
  • Phone: 319-369-7908
  • Fax:
Mailing address:
  • Phone: 515-471-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number24133
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0217869
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: