Provider Demographics
NPI:1104879170
Name:DALE M. GRUNEWALD DO PC
Entity type:Organization
Organization Name:DALE M. GRUNEWALD DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRUNEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-237-3974
Mailing Address - Street 1:230 S 68TH ST
Mailing Address - Street 2:SUITE 1203
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8176
Mailing Address - Country:US
Mailing Address - Phone:515-471-1800
Mailing Address - Fax:515-471-1801
Practice Address - Street 1:230 S 68TH ST
Practice Address - Street 2:SUITE 1203
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8176
Practice Address - Country:US
Practice Address - Phone:515-471-1800
Practice Address - Fax:515-471-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA02298Medicare UPIN