1124177407 NPI number — PRIMARY HEALTH CARE, INC.

Table of content: (NPI 1124177407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124177407 NPI number — PRIMARY HEALTH CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY HEALTH CARE, INC.
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:
PRIMARY HEALTH CARE-EAST SIDE CLINIC
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:
1124177407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50314-2355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-248-1447
Provider Business Mailing Address Fax Number:
515-248-1440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3509 E 29TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50317-4253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-248-1600
Provider Business Practice Location Address Fax Number:
515-248-1610
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTSMAN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
515-248-1441

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  NA , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0281857 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35586 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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