=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659573483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN IOWA MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1225 S GEAR AVE
-----------------------------------------------------
City | WEST BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52655-1691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-768-3323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 540
-----------------------------------------------------
City | WEST BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52655-0540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-768-3450
-----------------------------------------------------
Fax | 319-768-3460
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | CHERYL CLAWSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 319-768-3628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------