Basic Information
| Provider Information | |||||||||
| NPI: | 1871546762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST IOWA MEDICAL EDUCATION FOUNDATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHEAST IA FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 KIMBALL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192722112 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 KIMBALL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192722112 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | HOUGH | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3192722112 | ||||||||
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| 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 | 0137299 | 05 | IA | MEDICAID |