Provider Demographics
NPI:1346403755
Name:KENT P ELLERBROEK MD PC
Entity Type:Organization
Organization Name:KENT P ELLERBROEK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELLERBROEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-235-6323
Mailing Address - Street 1:541 KING DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5959
Mailing Address - Country:US
Mailing Address - Phone:319-235-6323
Mailing Address - Fax:319-235-0249
Practice Address - Street 1:541 KING DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5959
Practice Address - Country:US
Practice Address - Phone:319-235-6323
Practice Address - Fax:319-235-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA202213207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADN2700Medicare PIN
IA16980Medicare PIN