Provider Demographics
NPI:1467411793
Name:SPORTS MEDICINE DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE DIAGNOSTIC CENTER LLC
Other - Org Name:SOUTHERN IOWA OPEN MRI
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-683-1113
Mailing Address - Street 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6413
Mailing Address - Country:US
Mailing Address - Phone:641-683-1113
Mailing Address - Fax:641-683-1114
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 201B
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-683-1113
Practice Address - Fax:641-683-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0210245Medicaid
IA300133842OtherRAILROAD MEDICARE
IA22312OtherWELLMARK
IA0210245Medicaid