Healthcare Provider Details

I. General information

NPI: 1386376606
Provider Name (Legal Business Name): FAITH IBU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number86599
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2022023472
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number79922
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: