Basic Information
| Provider Information | |||||||||
| NPI: | 1588692487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PRIMARY HEALTH CARE-BERY ENGEBRETSEN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2353 SE 14TH ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503201109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481400 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNSTMAN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5152481441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NA | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0198614 | 05 | IA | MEDICAID | 29368 | 01 | IA | WELLMARK BCBS | OTHER |