=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942607411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIP N. FITCH OD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2014
-----------------------------------------------------
Last Update Date | 12/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 985 31ST ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52302-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-377-9735
-----------------------------------------------------
Fax | 319-373-2941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 985 31ST ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52302-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-377-9735
-----------------------------------------------------
Fax | 319-373-2941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PHILLIP N FITCH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 319-465-5114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 002491
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 002491
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------