Healthcare Provider Details

I. General information

NPI: 1053754663
Provider Name (Legal Business Name): TRIMARK PHYSICIANS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 5TH ST
STORM LAKE IA
50588-3027
US

IV. Provider business mailing address

802 KENYON RD
FORT DODGE IA
50501-5740
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-4030
  • Fax:
Mailing address:
  • Phone: 515-574-6603
  • Fax: 515-573-8710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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