Provider Demographics
NPI:1720086275
Name:BOOM, RALPH RIED (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:RIED
Last Name:BOOM
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:P.O. BOX 359
Mailing Address - Street 2:709 W MAIN ST
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-0359
Mailing Address - Country:US
Mailing Address - Phone:563-927-7985
Mailing Address - Fax:563-927-7934
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-927-7985
Practice Address - Fax:563-927-7934
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0210831Medicaid
A14482Medicare UPIN
IA24282Medicare PIN