Provider Demographics
NPI:1417025230
Name:GREAT RIVER MEDICAL SERVICES
Entity Type:Organization
Organization Name:GREAT RIVER MEDICAL SERVICES
Other - Org Name:BURLINGTON AREA FAMILY PRACTICE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:POETTING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-754-4242
Mailing Address - Street 1:1201 W AGENCY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1645
Mailing Address - Country:US
Mailing Address - Phone:319-754-4242
Mailing Address - Fax:319-754-4079
Practice Address - Street 1:1201 W AGENCY RD
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1645
Practice Address - Country:US
Practice Address - Phone:319-754-4242
Practice Address - Fax:319-754-4079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0198473Medicaid
IA0198473Medicaid