Healthcare Provider Details

I. General information

NPI: 1720086275
Provider Name (Legal Business Name): RALPH RIED BOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

IV. Provider business mailing address

P.O. BOX 359 709 W MAIN ST
MANCHESTER IA
52057-0359
US

V. Phone/Fax

Practice location:
  • Phone: 563-927-7985
  • Fax: 563-927-7934
Mailing address:
  • Phone: 563-927-7985
  • Fax: 563-927-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22897
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: