Provider Demographics
NPI:1588618011
Name:OTTUMWA NEUROLOGICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:OTTUMWA NEUROLOGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-682-4978
Mailing Address - Street 1:1313 N COURT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-1911
Mailing Address - Country:US
Mailing Address - Phone:641-682-4978
Mailing Address - Fax:641-682-0722
Practice Address - Street 1:1313 N COURT ST
Practice Address - Street 2:SUITE B
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-1911
Practice Address - Country:US
Practice Address - Phone:641-682-4978
Practice Address - Fax:641-682-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207R00000X, 2084N0400X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0421826Medicaid
IA0421826Medicaid
IAI9882Medicare ID - Type UnspecifiedMC GROUP ID #