MEDICARE: PROGENITY WHOLE HEALTH INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	1984	IA

General Provider Information

NPI Number	:	1245632298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGENITY WHOLE HEALTH INC.

Provider Business Mailing Address
First Line	:	1510 PLEASANT VIEW DR
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50315-2126
Country	:	US
Telephone Number	:	515-771-2527
Fax Number	:	855-642-1942

Provider Business Practice Location Address
First Line	:	1510 PLEASANT VIEW DR
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50315-2126
Country	:	US
Telephone Number	:	515-771-2527
Fax Number	:	855-642-1942

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MITCH HARRIS
Credential	:
Telephone Number	:	515-865-4567

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	12/13/2022

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