Provider Demographics
NPI:1932104593
Name:DIAGNOSTIC & CRITICAL CARE MEDICINE
Entity Type:Organization
Organization Name:DIAGNOSTIC & CRITICAL CARE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-865-4567
Mailing Address - Street 1:411 LAUREL ST
Mailing Address - Street 2:STE 3275
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3027
Mailing Address - Country:US
Mailing Address - Phone:515-247-4113
Mailing Address - Fax:515-643-8779
Practice Address - Street 1:1510 PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-2126
Practice Address - Country:US
Practice Address - Phone:515-771-2527
Practice Address - Fax:855-642-1942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0071233Medicaid
IA0071233Medicaid