Provider Demographics
NPI:1477665776
Name:FIFTH AVENUE OB GYN PC
Entity Type:Organization
Organization Name:FIFTH AVENUE OB GYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-243-4241
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:303 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3126
Practice Address - Country:US
Practice Address - Phone:515-243-4241
Practice Address - Fax:515-243-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01747207V00000X
IAF060593363LW0102X
IAF070928363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0112987Medicaid
IA0112987Medicaid
IAA14386Medicare UPIN