Provider Demographics
NPI:1679613723
Name:GREAT RIVER PHYSICIANS AND CLINICS INC
Entity Type:Organization
Organization Name:GREAT RIVER PHYSICIANS AND CLINICS INC
Other - Org Name:GREAT RIVER CLINIC AT WAPELLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-1000
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-0540
Mailing Address - Country:US
Mailing Address - Phone:319-768-3450
Mailing Address - Fax:319-768-3460
Practice Address - Street 1:220 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:WAPELLO
Practice Address - State:IA
Practice Address - Zip Code:52653-1570
Practice Address - Country:US
Practice Address - Phone:319-768-4085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0638494Medicaid
IACH9435OtherRR MEDICARE
IA163849Medicare Oscar/Certification
IA0638494Medicaid