Healthcare Provider Details

I. General information

NPI: 1780610055
Provider Name (Legal Business Name): IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N COLLEGE AVE STE 120
GENESEO IL
61254-1092
US

IV. Provider business mailing address

8101 BIRCHWOOD COURT SUITE R
JOHNSTON IA
50131-2930
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-5342
  • Fax: 309-945-4079
Mailing address:
  • Phone: 515-471-9243
  • Fax: 515-471-9319

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