Basic Information
| Provider Information | |||||||||
| NPI: | 1699880138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AFFILIATES OF FAMILY PRACTICE OF CEDAR RAPIDS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AFFILIATES OF FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 5TH AVENUE SE | ||||||||
| Address2: | SUITE 1700 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193647730 | ||||||||
| FaxNumber: | 3193640240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 5TH AVENUE SE | ||||||||
| Address2: | SUITE 1700 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193647730 | ||||||||
| FaxNumber: | 3193640240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CEARLOCK | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3193647730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34383 | IA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 22198 | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0253740 | 05 | IA | MEDICAID |