Healthcare Provider Details

I. General information

NPI: 1124026489
Provider Name (Legal Business Name): FAMILY MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 9TH AVE N
SIBLEY IA
51249-1012
US

IV. Provider business mailing address

600 9TH AVE N PO BOX 277
SIBLEY IA
51249-1012
US

V. Phone/Fax

Practice location:
  • Phone: 712-754-3658
  • Fax: 712-754-2634
Mailing address:
  • Phone: 712-754-3658
  • Fax: 712-754-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18374
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18381
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02364
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02096
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3511
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number18374
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number18374
License Number StateIA

VIII. Authorized Official

Name: DR. WILLIAM EARL HICKS
Title or Position: PARTNER
Credential: M.D.
Phone: 712-754-3658