Healthcare Provider Details

I. General information

NPI: 1922002591
Provider Name (Legal Business Name): RIVER CITIES INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAIN AVE
CLINTON IA
52732-2241
US

IV. Provider business mailing address

221 MAIN AVE
CLINTON IA
52732-2241
US

V. Phone/Fax

Practice location:
  • Phone: 563-242-7522
  • Fax: 563-242-7534
Mailing address:
  • Phone: 563-242-7522
  • Fax: 563-242-7534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22254
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00961
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA-077904
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA-080599
License Number StateIA

VIII. Authorized Official

Name: DOUGLAS J JERGENSON
Title or Position: PRESIDENT
Credential: MD
Phone: 563-242-7522