Provider Demographics
NPI:1841217916
Name:RENAL DIALYSIS ASSOCIATES OF DAVENPORT,P.C.
Entity Type:Organization
Organization Name:RENAL DIALYSIS ASSOCIATES OF DAVENPORT,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:STIBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-326-6273
Mailing Address - Street 1:1228 E RUSHOLME ST STE 8
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2467
Mailing Address - Country:US
Mailing Address - Phone:563-326-6256
Mailing Address - Fax:563-326-0098
Practice Address - Street 1:1228 E RUSHOLME ST STE 8
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2467
Practice Address - Country:US
Practice Address - Phone:563-326-6256
Practice Address - Fax:563-326-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1074807Medicaid
IA1074807Medicaid