Provider Demographics
NPI:1225433675
Name:PRUCHNO MEDICINE, LLC
Entity Type:Organization
Organization Name:PRUCHNO MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRUCHNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-247-3899
Mailing Address - Street 1:PO BOX 1112
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1112
Mailing Address - Country:US
Mailing Address - Phone:319-247-3899
Mailing Address - Fax:
Practice Address - Street 1:202 10TH ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2414
Practice Address - Country:US
Practice Address - Phone:319-247-3899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27892207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1101865Medicaid
IA1101865Medicaid