Provider Demographics
NPI:1548310394
Name:JOHN M. IPPOLITO MD, P.C
Entity type:Organization
Organization Name:JOHN M. IPPOLITO MD, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:IPPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-256-0791
Mailing Address - Street 1:201 RIDGE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4643
Mailing Address - Country:US
Mailing Address - Phone:712-256-0791
Mailing Address - Fax:712-256-0807
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-256-0791
Practice Address - Fax:712-256-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1044065Medicaid
NE1548310394Medicaid
NE1548310394Medicaid