Basic Information
Provider Information | |||||||||
NPI: | 1295197242 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUBBELL | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | DALE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 HAWKINS DR | ||||||||
Address2: |   | ||||||||
City: | IOWA CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 522421009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2160 S 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | MAYWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 601533328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082169000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2016 | ||||||||
LastUpdateDate: | 09/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 267550 | MA | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YP0228X | R-12193 | IA | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YP0228X | 036160130 | IL | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207Y00000X | 036160130 | IL | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.