=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639307192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN E STITH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2009
-----------------------------------------------------
Last Update Date | 11/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1018 DUFF AVE
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-663-8621
-----------------------------------------------------
Fax | 515-663-8620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 BANK ST
-----------------------------------------------------
City | WEBSTER CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50595-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-832-6700
-----------------------------------------------------
Fax | 515-832-3534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 7182
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 04620
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------