Basic Information
Provider Information | |||||||||
NPI: | 1811945587 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | APLINGTON-PARKERSBURG FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8101 BIRCHWOOD CT | ||||||||
Address2: | SUITE R | ||||||||
City: | JOHNSTON | ||||||||
State: | IA | ||||||||
PostalCode: | 501312930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5154719243 | ||||||||
FaxNumber: | 5154719319 | ||||||||
Practice Location | |||||||||
Address1: | 502 3RD ST | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | IA | ||||||||
PostalCode: | 506652063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193462331 | ||||||||
FaxNumber: | 3193461531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 08/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAINE | ||||||||
AuthorizedOfficialFirstName: | ERICK | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 5154719227 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 0689034 | 05 | IA |   | MEDICAID |