Provider Demographics
NPI:1730188160
Name:GREATER DES MOINES DERMATOLOGY PC
Entity type:Organization
Organization Name:GREATER DES MOINES DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:ABRAHAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-243-8676
Mailing Address - Street 1:2424 128TH ST
Mailing Address - Street 2:NW 128TH STREET
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50323-1816
Mailing Address - Country:US
Mailing Address - Phone:515-243-8676
Mailing Address - Fax:515-243-0487
Practice Address - Street 1:2424 128TH ST
Practice Address - Street 2:NW 128TH STREET
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50323-1816
Practice Address - Country:US
Practice Address - Phone:515-243-8676
Practice Address - Fax:515-243-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33182207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0255075Medicaid
IAH34252Medicare UPIN
IAI4908Medicare PIN