1548269301 NPI number — NEW CENTURY PHYSICIANS OF IOWA PC

Table of content: CAMERON BRAY (NPI 1972258077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548269301 NPI number — NEW CENTURY PHYSICIANS OF IOWA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW CENTURY PHYSICIANS OF IOWA PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548269301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4750 HEMPSTEAD STATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45429-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-875-0136
Provider Business Mailing Address Fax Number:
937-619-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MERCY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-3128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-328-5230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HOLTZCLAW
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-686-4316

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  275930 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0298018 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100251147-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112607000 . This is a "DEPT OF LABOR" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 34944 . This is a "BC/BS GRP PROVIDER NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 112607000 . This is a "EEOICP" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 112607000 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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