Healthcare Provider Details

I. General information

NPI: 1285005850
Provider Name (Legal Business Name): IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N COLLEGE AVE SUITE 120
GENESEO IL
61254-1095
US

IV. Provider business mailing address

600 N COLLEGE AVE SUITE 120
GENESEO IL
61254-1095
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-5342
  • Fax: 309-945-4079
Mailing address:
  • Phone: 309-944-5342
  • Fax: 309-945-4079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: ERICK J LAINE
Title or Position: VP/COO
Credential:
Phone: 515-471-9227