Healthcare Provider Details

I. General information

NPI: 1053627182
Provider Name (Legal Business Name): NEUROPSYCHIATRIC MEDICINE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 S 3RD ST
CLINTON IA
52732-4357
US

IV. Provider business mailing address

PO BOX 321
CLINTON IA
52733-0321
US

V. Phone/Fax

Practice location:
  • Phone: 319-217-2566
  • Fax:
Mailing address:
  • Phone: 319-217-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number27692
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier27692
Identifier TypeOTHER
Identifier StateID
Identifier IssuerIOWA LICENSE

VIII. Authorized Official

Name: DR. JOSHUA E NNANJI
Title or Position: OWNER
Credential: MD
Phone: 319-217-2566