=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154355840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAGARATHNAMMA NADIPURAM, MD, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 07/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 W DALE ST
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50703-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-235-3178
-----------------------------------------------------
Fax | 319-274-6776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2400
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50704-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-233-3044
-----------------------------------------------------
Fax | 319-233-0722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NAGARATHNAMMA NADIPURAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 319-235-3178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------