MEDICARE: GWEN R RADKE OT

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	225X00000X	Occupational Therapist	1220	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01760	OTHER	IA	WELLMARK BCBS OF IOWA

General Provider Information

NPI Number	:	1962540724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN R RADKE OT

Provider Business Mailing Address
First Line	:	505 N CRAIG DR
Second Line	:
City	:	CHEROKEE
State	:	IA
Zip	:	51012-1107
Country	:	US
Telephone Number	:	712-261-5877
Fax Number	:

Provider Business Practice Location Address
First Line	:	4319 NW URBANDALE DR
Second Line	:
City	:	URBANDALE
State	:	IA
Zip	:	50322-7910
Country	:	US
Telephone Number	:	515-225-4070
Fax Number	:

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

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	11/09/2022

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Directions to “ GWEN R RADKE OT” Practice Location

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