1508270703 NPI number — FAMILY FIRST MEDICAL, PLLC

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 1508270703 NPI number — FAMILY FIRST MEDICAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FIRST MEDICAL, PLLC
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:
1508270703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50312-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-237-3974
Provider Business Mailing Address Fax Number:
515-883-2692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 E BUCHANAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50028-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-227-3045
Provider Business Practice Location Address Fax Number:
641-227-3046
Provider Enumeration Date:
06/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PEARSON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
641-831-3215

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  098752 , 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: IN PROCESS . This is a "BCBS OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: IN PROCESS , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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