Provider Demographics
NPI:1194991109
Name:DES MOINES PEDIATRIC & ADOLESCENT CLINIC
Entity type:Organization
Organization Name:DES MOINES PEDIATRIC & ADOLESCENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:FORNOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-255-3181
Mailing Address - Street 1:2301 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3903
Mailing Address - Country:US
Mailing Address - Phone:515-255-3181
Mailing Address - Fax:515-255-9392
Practice Address - Street 1:2301 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3903
Practice Address - Country:US
Practice Address - Phone:515-255-3181
Practice Address - Fax:515-255-9392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty