Basic Information
Provider Information | |||||||||
NPI: | 1831114578 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | IOWA HEALTH PHYSICIANS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8101 BIRCHWOOD COURT | ||||||||
Address2: | SUITE R | ||||||||
City: | JOHNSTON | ||||||||
State: | IA | ||||||||
PostalCode: | 501312930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5154719243 | ||||||||
FaxNumber: | 5154719319 | ||||||||
Practice Location | |||||||||
Address1: | 6000 UNIVERSITY AVENUE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | WEST DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 502668200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152412200 | ||||||||
FaxNumber: | 5152412201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 02/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCNICHOLS | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
AuthorizedOfficialTelephone: | 5154719201 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.