Basic Information
| Provider Information | |||||||||
| NPI: | 1891771663 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MMSC VENTURES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STATE CENTER FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 SOUTH 4TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501582998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417545151 | ||||||||
| FaxNumber: | 6417545181 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 3RD AVE SW | ||||||||
| Address2: | |||||||||
| City: | STATE CENTER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502477719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414832141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 12/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOWNEY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6417545125 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MMSC VENTURES INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 0685214 | 05 | IA | MEDICAID | 47411 | 01 | IA | BLUE SHIELD OF IOWA | OTHER |