Healthcare Provider Details

I. General information

NPI: 1265701783
Provider Name (Legal Business Name): TRIMARK PHYSICIANS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 L ST
FORT DODGE IA
50501-5706
US

IV. Provider business mailing address

24 N 9TH ST SUITE A
FORT DODGE IA
50501-3905
US

V. Phone/Fax

Practice location:
  • Phone: 515-574-6015
  • Fax: 515-574-6016
Mailing address:
  • Phone: 515-574-6890
  • Fax: 515-574-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J. DEWERFF
Title or Position: CFO
Credential:
Phone: 515-574-6603