Healthcare Provider Details

I. General information

NPI: 1649649484
Provider Name (Legal Business Name): POG CEDAR RAPIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH ST SE STE 285
CEDAR RAPIDS IA
52403-2414
US

IV. Provider business mailing address

PO BOX 1086
DUBUQUE IA
52004-1086
US

V. Phone/Fax

Practice location:
  • Phone: 319-861-6944
  • Fax: 319-861-6945
Mailing address:
  • Phone: 563-556-3175
  • Fax: 563-594-5256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: NAGENDRA S KONERU
Title or Position: OWNER
Credential: MD
Phone: 563-556-3175