Basic Information
| Provider Information | |||||||||
| NPI: | 1336523893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONVENIENT CARE MEDICAL GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3502 METRO DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515017724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122567172 | ||||||||
| FaxNumber: | 7122567374 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 METRO DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515017724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122567172 | ||||||||
| FaxNumber: | 7122567374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | WYATT | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAIN ASSISTANT/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7122567172 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | A121973 | IA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | 002355 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.