1245288661 NPI number — IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245288661 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:
SHELLSBURG 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:
1245288661
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:
400 CANTON ST NW
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SHELLSBURG
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52332-9645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-436-2040
Provider Business Practice Location Address Fax Number:
319-436-2027
Provider Enumeration Date:
05/05/2006

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: 0689083 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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