Provider Demographics
NPI:1104163179
Name:MARY NELSON MD PC
Entity type:Organization
Organization Name:MARY NELSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-365-8616
Mailing Address - Street 1:411 10TH ST SE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2442
Mailing Address - Country:US
Mailing Address - Phone:319-365-8616
Mailing Address - Fax:319-297-7377
Practice Address - Street 1:411 10TH ST SE
Practice Address - Street 2:SUITE 1400
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2442
Practice Address - Country:US
Practice Address - Phone:319-365-8616
Practice Address - Fax:319-297-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA14503Medicare UPIN