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General NPI Number Information
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NPI Number | 1225076029
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Entity Type | Individual
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Provider Name | GREG EVAN RAECKER DO
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Gender | Male
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 09/07/2007
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Provider Practice Location Address
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Address Line | 1731 W RIDGEWAY AVE STE 101
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City | WATERLOO
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State | IA
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Zip | 50701-4591
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Country | US
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Telephone | 319-833-6001
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Fax | 319-833-6003
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Provider Business Mailing Address
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Address Line | PO BOX 2758
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City | WATERLOO
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State | IA
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Zip | 50704-2758
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Country | US
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Telephone | 319-833-6001
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Fax | 319-833-6003
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 02087
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License Number State | IA
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