Basic Information
| Provider Information | |||||||||
| NPI: | 1124072814 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES OF CLINTON, IOWA, P.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEWITT FAMILY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 13TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632432511 | ||||||||
| FaxNumber: | 5632430817 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 11TH ST | ||||||||
| Address2: | |||||||||
| City: | DE WITT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527421209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5636599294 | ||||||||
| FaxNumber: | 5636598104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | MOSER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5632432511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL ASSOCIATE OF CLINTON IOWA, P.L.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 44018 | 05 | IA | MEDICAID |