Provider Demographics
NPI:1922002591
Name:RIVER CITIES INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:RIVER CITIES INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:JERGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-242-7522
Mailing Address - Street 1:221 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2241
Mailing Address - Country:US
Mailing Address - Phone:563-242-7522
Mailing Address - Fax:563-242-7534
Practice Address - Street 1:221 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2241
Practice Address - Country:US
Practice Address - Phone:563-242-7522
Practice Address - Fax:563-242-7534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22254207R00000X
IA00961363A00000X
IAA-077904363L00000X
IAA-080599363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA46206Medicare PIN
IA46206Medicare ID - Type Unspecified