1114912813 NPI number — FAMILY PRACTICE CLINIC PLC

Table of content: (NPI 1114912813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114912813 NPI number — FAMILY PRACTICE CLINIC PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRACTICE CLINIC PLC
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:
Provider Other Organization Name Type Code:
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:
1114912813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 SCHOOL ST
Provider Second Line Business Mailing Address:
PO BOX F
Provider Business Mailing Address City Name:
CARLISLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50047-0705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-989-3221
Provider Business Mailing Address Fax Number:
515-989-4518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 SCHOOL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLISLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50047-8702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-989-3221
Provider Business Practice Location Address Fax Number:
515-989-4518
Provider Enumeration Date:
09/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCCORMICK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
515-989-3221

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5656790001 . This is a "DMERC REGION D" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: IA0100 . This is a "HERITAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07022 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0479345 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07022 . This is a "BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 124831 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DE5916 . This is a "PALMETTO GBA RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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