Provider Demographics
NPI:1043392665
Name:GLEASON DIAGNOSTIC IMAGING, PC
Entity Type:Organization
Organization Name:GLEASON DIAGNOSTIC IMAGING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-230-3363
Mailing Address - Street 1:PO BOX 2085
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-0085
Mailing Address - Country:US
Mailing Address - Phone:515-230-3363
Mailing Address - Fax:712-239-3711
Practice Address - Street 1:1015 UNION ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-4821
Practice Address - Country:US
Practice Address - Phone:515-432-3140
Practice Address - Fax:515-433-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0415497Medicaid
IAI10451Medicare ID - Type Unspecified