Basic Information
| Provider Information | |||||||||
| NPI: | 1437428612 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRIMARK PHYSICIANS GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNITYPOINT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 KENYON RD | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155746890 | ||||||||
| FaxNumber: | 5155746458 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW | ||||||||
| State: | IA | ||||||||
| PostalCode: | 514507717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126578513 | ||||||||
| FaxNumber: | 7126572939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2011 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWERFF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5155746603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRIMARK PHYSICIANS GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.