Basic Information
| Provider Information | |||||||||
| NPI: | 1336127828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIOUXLAND MEDICAL EDUCATION FOUNDATION, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122945000 | ||||||||
| FaxNumber: | 7122945091 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122945000 | ||||||||
| FaxNumber: | 7122945091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | WERNER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7122945000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 0146191 | 05 | IA | MEDICAID | 14619 | 01 | IA | MEDICARE GROUP | OTHER |