MEDICARE: ELLEN LOUISE SAKORNBUT MD

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	207Q00000X	Family Medicine Physician	34687	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	38764	OTHER	IA	WELLMARK (BC/BS)

General Provider Information

NPI Number	:	1578567947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN LOUISE SAKORNBUT MD

Provider Business Mailing Address
First Line	:	220 W RIDGEWAY AVE
Second Line	:	SUITE 106
City	:	WATERLOO
State	:	IA
Zip	:	50701-4200
Country	:	US
Telephone Number	:	319-226-4400
Fax Number	:	319-226-4401

Provider Business Practice Location Address
First Line	:	220 W RIDGEWAY AVE
Second Line	:	SUITE 106
City	:	WATERLOO
State	:	IA
Zip	:	50701-4200
Country	:	US
Telephone Number	:	319-226-4400
Fax Number	:	319-226-4401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	07/09/2007

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