Provider Demographics
NPI:1427003011
Name:OBSTETRICS AND GYNECOLOGY SPECIALISTS PC
Entity Type:Organization
Organization Name:OBSTETRICS AND GYNECOLOGY SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-355-1853
Mailing Address - Street 1:5350 EASTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-355-1853
Mailing Address - Fax:563-355-0327
Practice Address - Street 1:5350 EASTERN AVENUE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-355-1853
Practice Address - Fax:563-355-0327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA9242Medicare ID - Type Unspecified