Basic Information
Provider Information | |||||||||
NPI: | 1295713261 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST IOWA SURGEONS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 E 10TH ST | ||||||||
Address2: |   | ||||||||
City: | WACONIA | ||||||||
State: | MN | ||||||||
PostalCode: | 553874552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524429770 | ||||||||
FaxNumber: | 9524423620 | ||||||||
Practice Location | |||||||||
Address1: | 1823 HIGHWAY BLVD STE 5 | ||||||||
Address2: |   | ||||||||
City: | SPENCER | ||||||||
State: | IA | ||||||||
PostalCode: | 513012226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122626320 | ||||||||
FaxNumber: | 9524423620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2006 | ||||||||
LastUpdateDate: | 04/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SLATTERY | ||||||||
AuthorizedOfficialFirstName: | PATRICK | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7122626320 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD, FACS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0415950 | 05 | IA |   | MEDICAID |