Basic Information
| Provider Information | |||||||||
| NPI: | 1366497257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADEL FAMILY MEDICAL CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
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| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 GREENE ST | ||||||||
| Address2: | |||||||||
| City: | ADEL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500031712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159934656 | ||||||||
| FaxNumber: | 5158834532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 06/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | DONAHUE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5152373974 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0282764 | 05 | IA | MEDICAID |