Provider Demographics
NPI:1265434864
Name:KANNENBERG, JAMES G (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:KANNENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1194928Medicaid
IA25668OtherIOWA HEALTH SOLUTIONS
IA45020OtherWELLMARK BLUE CROSS
IAIA0122OtherJOHN DEERE HEALTH
IA45020Medicare PIN
IA25668OtherIOWA HEALTH SOLUTIONS