Provider Demographics
NPI:1891773271
Name:PRUCHNICKI, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:PRUCHNICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 UNIVERSITY AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5945
Mailing Address - Country:US
Mailing Address - Phone:515-401-1950
Mailing Address - Fax:515-401-1955
Practice Address - Street 1:4200 UNIVERSITY AVE STE 300
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5945
Practice Address - Country:US
Practice Address - Phone:515-401-1950
Practice Address - Fax:515-401-1955
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26940207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4267OtherMIDLANDS PROVIDER #
IAIA0122OtherJOHN DEERE PROVIDER #
IA26940OtherTRICARE PROVIDER #
IA27660OtherBLUE SHIELD PROVIDER #
IA050035373OtherRAILROAD MEDICARE #
IA0058420Medicaid
IA27660Medicare ID - Type UnspecifiedMEDICARE PROVIDER #