Basic Information
| Provider Information | |||||||||
| NPI: | 1285784983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS' CLINIC OF IOWA, PC, DEPT OF ENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193992022 | ||||||||
| FaxNumber: | 3193992014 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193992022 | ||||||||
| FaxNumber: | 3193992014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3193981772 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 56461 | 01 | IA | WELLMARK GROUP NUMBER | OTHER |