Provider Demographics
NPI:1750360251
Name:GREAT RIVER MEDICAL GROUP
Entity type:Organization
Organization Name:GREAT RIVER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PTR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:563-441-9100
Mailing Address - Street 1:4626 PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3483
Mailing Address - Country:US
Mailing Address - Phone:563-441-9100
Mailing Address - Fax:563-441-9101
Practice Address - Street 1:4626 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3483
Practice Address - Country:US
Practice Address - Phone:563-441-9100
Practice Address - Fax:563-441-9101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14546Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER