Provider Demographics
NPI:1104870690
Name:DIAGNOSTIC & INT MED ASSOC PC
Entity type:Organization
Organization Name:DIAGNOSTIC & INT MED ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KRICSFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACP
Authorized Official - Phone:712-322-5532
Mailing Address - Street 1:201 RIDGE ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4643
Mailing Address - Country:US
Mailing Address - Phone:712-322-5532
Mailing Address - Fax:800-293-4214
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 302
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-322-5532
Practice Address - Fax:800-293-4214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0129437Medicaid
IACP8208OtherRAILROAD MEDICARE
NE099449Medicare PIN
IACP8208OtherRAILROAD MEDICARE