Provider Demographics
NPI:1861551665
Name:GARY VOLENTINE MD
Entity type:Organization
Organization Name:GARY VOLENTINE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MISS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:K
Authorized Official - Last Name:COLEGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:712-322-2332
Mailing Address - Street 1:801 HARMONY ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3106
Mailing Address - Country:US
Mailing Address - Phone:712-322-2332
Mailing Address - Fax:712-322-5122
Practice Address - Street 1:801 HARMONY ST
Practice Address - Street 2:SUITE 404
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3106
Practice Address - Country:US
Practice Address - Phone:712-322-2332
Practice Address - Fax:712-322-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107489363LF0000X
IA21611207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3941278Medicaid
IAI9316Medicare PIN