Provider Demographics
NPI:1841569936
Name:CHAUTAUQUA CLINIC
Entity Type:Organization
Organization Name:CHAUTAUQUA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR PSYCHIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:ENGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-472-7216
Mailing Address - Street 1:2709 W BRIGGS AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-2649
Mailing Address - Country:US
Mailing Address - Phone:641-472-7216
Mailing Address - Fax:641-209-6690
Practice Address - Street 1:2709 W BRIGGS AVE STE 4
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-2649
Practice Address - Country:US
Practice Address - Phone:641-472-7216
Practice Address - Fax:641-209-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA231262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0056978Medicaid
IA0056978Medicaid