Provider Demographics
NPI:1588893911
Name:GERDTS PODIATRIC LLC
Entity type:Organization
Organization Name:GERDTS PODIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GERDTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:641-832-7540
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3621
Practice Address - Street 1:616 N 8TH ST
Practice Address - Street 2:
Practice Address - City:OSAGE
Practice Address - State:IA
Practice Address - Zip Code:50461-1456
Practice Address - Country:US
Practice Address - Phone:641-732-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-07
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00722213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADQ3207OtherMEDICARE RAILROAD
IAIB1476Medicare PIN
IADQ3207OtherMEDICARE RAILROAD