Active NPI
Sports Medicine Diagnostic Center LLC
- Magnetic Resonance Imaging Radiologic Technologist
- Ottumwa, IA
National Provider Identifier
1467411793
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Magnetic Resonance Imaging Radiologic Technologist
- Legal business name
- SPORTS MEDICINE DIAGNOSTIC CENTER LLC
- Practice address
- 1005 Pennsylvania Ave
Suite 201B
Ottumwa, IA 52501-6413 - Phone
- (641) 683-1113
- Fax
- (641) 683-1114
- NPI assigned
- Mar 23, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Donald D Berg, M.D.
- Title
- Manager
- Phone
- (641) 683-1113
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Magnetic Resonance Imaging Radiologic Technologist | 2471M1202X | Primary |
Addresses
Primary practice location
1005 Pennsylvania Ave
Suite 201B
Ottumwa, IA 52501-6413
Mailing address
1005 Pennsylvania Ave
Suite 201B
Ottumwa, IA 52501-6413
Phone (641) 683-1113
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0210245 | Medicaid | IA | |
| 300133842 | Other | IA | RAILROAD MEDICARE |
| 22312 | Other | IA | WELLMARK |
Other names 1
- SOUTHERN IOWA OPEN MRI
National Provider Directory
National Provider DirectoryLocations
1005 Pennsylvania Ave
Ste 201B
Ottumwa, IA 52501
Phone (641) 683-1113
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1143072000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1329868800000",
"number": "1467411793",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1005 PENNSYLVANIA AVE",
"address_2": "SUITE 201B",
"city": "OTTUMWA",
"state": "IA",
"postal_code": "525016413",
"telephone_number": "641-683-1113",
"fax_number": "641-683-1114"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1005 PENNSYLVANIA AVE",
"address_2": "SUITE 201B",
"city": "OTTUMWA",
"state": "IA",
"postal_code": "525016413",
"telephone_number": "641-683-1113",
"fax_number": "641-683-1114"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SPORTS MEDICINE DIAGNOSTIC CENTER LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-03-23",
"last_updated": "2012-02-22",
"status": "A",
"authorized_official_last_name": "BERG",
"authorized_official_first_name": "DONALD",
"authorized_official_middle_name": "D",
"authorized_official_title_or_position": "MANAGER",
"authorized_official_telephone_number": "641-683-1113",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "M.D."
},
"taxonomies": [
{
"code": "2471M1202X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Radiologic Technologist, Magnetic Resonance Imaging",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0210245",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "300133842",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WELLMARK",
"identifier": "22312",
"state": "IA"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "SOUTHERN IOWA OPEN MRI",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Ottumwa, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 22, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.