Basic Information
| Provider Information | |||||||||
| NPI: | 1174073597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITYPOINT CLINIC URGENT CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRIMACK PHYSICIANS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 802 KENYON RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155748484 | ||||||||
| FaxNumber: | 5155748483 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 KENYON RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155748484 | ||||||||
| FaxNumber: | 5155748483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5155748488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | A113462 | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.