Provider Demographics
NPI:1053452391
Name:GREAT RIVER PHYSICIANS AND CLINICS INC
Entity Type:Organization
Organization Name:GREAT RIVER PHYSICIANS AND CLINICS INC
Other - Org Name:GREAT RIVER HEALTH-MEDIAPOLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-1000
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-0540
Mailing Address - Country:US
Mailing Address - Phone:319-768-3450
Mailing Address - Fax:319-768-3460
Practice Address - Street 1:401 N ORCHARD ST
Practice Address - Street 2:
Practice Address - City:MEDIAPOLIS
Practice Address - State:IA
Practice Address - Zip Code:52637
Practice Address - Country:US
Practice Address - Phone:319-394-3177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0689513Medicaid
IACG2275OtherRR MEDICARE
IA0689513Medicaid
IA168951Medicare Oscar/Certification