Healthcare Provider Details

I. General information

NPI: 1780281915
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, IOWA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 HEARTLAND DR
CORALVILLE IA
52241-2733
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 319-645-4001
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599