Basic Information
| Provider Information | |||||||||
| NPI: | 1871542175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LAKEVIEW INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8101 BIRCHWOOD CT | ||||||||
| Address2: | SUITE R | ||||||||
| City: | JOHNSTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501312930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154719243 | ||||||||
| FaxNumber: | 5154719319 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502668203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152412400 | ||||||||
| FaxNumber: | 5152412401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 08/16/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| 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 | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.