NPIMap

Organization Active NPI

Cedar Centre Psychiatric Group

  • Psychiatry Physician
  • Cedar Rapids, IA
National Provider Identifier
1558338012
Registry record updated Feb 25, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
CEDAR CENTRE PSYCHIATRIC GROUP
Practice address
1730 1St Ave NE
Cedar Rapids, IA 52402-5433
Phone
(319) 365-3993
Fax
(319) 364-0116
NPI assigned
Mar 3, 2006
Last updated
Feb 25, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Bryan Netolicky, M.D.NPI 1255405338
Title
Partner
Phone
(319) 365-3993

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Counselor 101YM0800X IA
Psychologist 103T00000X IA
Counseling Psychologist 103TC1900X IA
Clinical Social Worker 1041C0700X IA
Psychiatry Physician 2084P0800X IA Primary

Addresses

Primary practice location

1730 1St Ave NE
Cedar Rapids, IA 52402-5433

Mailing address

PO Box 1408
Cedar Rapids, IA 52406-1408
Phone (319) 365-3993

Other identifiers 2

IdentifierTypeStateIssuer
17415OtherIAWELLMARK BC/BS
0174151MedicaidIA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040319001123 IA Part B Supplier - Clinic/Group Practice 6204726342 Receives reassigned benefits from 12 practitioners
Practice locations: Cedar Rapids, IA

National Provider Directory

National Provider Directory

Locations

1730 1st Ave NE
Cedar Rapids, IA 52402
Phone (319) 365-3993

Practitioners & affiliated clinicians

Practitioners 35

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 35

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141344000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456358400000",
    "number": "1558338012",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1408",
            "city": "CEDAR RAPIDS",
            "state": "IA",
            "postal_code": "524061408",
            "telephone_number": "319-365-3993",
            "fax_number": "319-364-0116"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1730 1ST AVE NE",
            "city": "CEDAR RAPIDS",
            "state": "IA",
            "postal_code": "524025433",
            "telephone_number": "319-365-3993",
            "fax_number": "319-364-0116"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CEDAR CENTRE PSYCHIATRIC GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-03",
        "last_updated": "2016-02-25",
        "status": "A",
        "authorized_official_last_name": "NETOLICKY",
        "authorized_official_first_name": "BRYAN",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "319-365-3993",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "",
            "desc": "Psychologist, Counseling",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IA",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "IA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK BC/BS",
            "identifier": "17415",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0174151",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cedar Rapids, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.