Healthcare Provider Details

I. General information

NPI: 1336523893
Provider Name (Legal Business Name): CONVENIENT CARE MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 METRO DRIVE SUITE 200
COUNCIL BLUFFS IA
51501-7724
US

IV. Provider business mailing address

3502 METRO DRIVE SUITE 200
COUNCIL BLUFFS IA
51501-7724
US

V. Phone/Fax

Practice location:
  • Phone: 712-256-7172
  • Fax: 712-256-7374
Mailing address:
  • Phone: 712-256-7172
  • Fax: 712-256-7374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002355
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA121973
License Number StateIA

VIII. Authorized Official

Name: WYATT ALLEN SCHMIDT
Title or Position: PHYSICAIN ASSISTANT/MANAGER
Credential: PA-C
Phone: 712-256-7172