Basic Information
| Provider Information | |||||||||
| NPI: | 1750382347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUNTRYMAN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 NE DARTMOOR DR | ||||||||
| Address2: | |||||||||
| City: | WAUKEE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759890 | ||||||||
| FaxNumber: | 5158759892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/22/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO-02312 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043646 | 05 | IA | MEDICAID | 59276 | 01 | IN | WELLMARK BCBS | OTHER |