Basic Information
| Provider Information | |||||||||
| NPI: | 1043269079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANAMOSA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8101 BIRCHWOOD COURT | ||||||||
| Address2: | SUITE R | ||||||||
| City: | JOHNSTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501312930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154719243 | ||||||||
| FaxNumber: | 5154719319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1791 HIGHWAY 64 E | ||||||||
| Address2: | |||||||||
| City: | ANAMOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522052112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194623571 | ||||||||
| FaxNumber: | 3194626043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | LAINE | ||||||||
| AuthorizedOfficialFirstName: | ERICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5154719227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
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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 | 0638940 | 05 | IA | MEDICAID |