Provider Demographics
NPI:1528029170
Name:JENNINGS, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 PIERCE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1058
Mailing Address - Country:US
Mailing Address - Phone:712-226-2600
Mailing Address - Fax:712-226-2605
Practice Address - Street 1:4545 SERGEANT RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4706
Practice Address - Country:US
Practice Address - Phone:712-274-2400
Practice Address - Fax:712-274-1484
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD28378OtherSIOUX VALLEY
IA47474OtherWELLMARK BCBS
143OtherMIDLANDS CHOICE
75305796351106B005OtherTRICARE
SD7777682Medicaid
IA1219675Medicaid
SD216089OtherDAKOTA CARE
NE75305796313Medicaid
080187500Medicare ID - Type UnspecifiedRAILROAD
75305796351106B005OtherTRICARE
IAI6930Medicare ID - Type Unspecified