1194760561 NPI number — IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION

Table of content: (NPI 1194760561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194760561 NPI number — IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLARENCE FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194760561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8101 BIRCHWOOD COURT
Provider Second Line Business Mailing Address:
SUITE R
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50131-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-471-9243
Provider Business Mailing Address Fax Number:
515-471-9319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARENCE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52216-9744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-452-3211
Provider Business Practice Location Address Fax Number:
563-452-3215
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAINE
Authorized Official First Name:
ERICK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
515-471-9227

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0638981 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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