Basic Information
| Provider Information | |||||||||
| NPI: | 1316264252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8101 BIRCHWOOD COURT | ||||||||
| Address2: | SUITE R | ||||||||
| City: | JOHNSTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501312930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154719243 | ||||||||
| FaxNumber: | 5154719319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 SOUTH HACKETT ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192741000 | ||||||||
| FaxNumber: | 3192926526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 12/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCNICHOLS | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
| AuthorizedOfficialTelephone: | 5154719201 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | CC6519 | 01 | IA | RR MEDICARE | OTHER | 1366425274 | 05 | IA | MEDICAID |