Healthcare Provider Details

I. General information

NPI: 1053452391
Provider Name (Legal Business Name): GREAT RIVER PHYSICIANS AND CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N ORCHARD ST
MEDIAPOLIS IA
52637
US

IV. Provider business mailing address

PO BOX 540
WEST BURLINGTON IA
52655-0540
US

V. Phone/Fax

Practice location:
  • Phone: 319-394-3177
  • Fax:
Mailing address:
  • Phone: 319-768-3450
  • Fax: 319-768-3460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TONY HAYES
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 319-768-1000