Provider Demographics
NPI:1619115888
Name:ALL AGES PEDIATRICS PC
Entity Type:Organization
Organization Name:ALL AGES PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES CEO CFO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:641-682-5437
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 1:1207 N JEFFERSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2021
Practice Address - Country:US
Practice Address - Phone:641-682-5437
Practice Address - Fax:641-682-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAH79889Medicare UPIN