=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790161255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIMARK PHYSICIANS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2015
-----------------------------------------------------
Last Update Date | 08/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 11TH AVE
-----------------------------------------------------
City | MANSON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50563-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-469-3307
-----------------------------------------------------
Fax | 712-469-2614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 KENYON RD
-----------------------------------------------------
City | FORT DODGE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50501-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-574-6890
-----------------------------------------------------
Fax | 515-574-6458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL J DEWERFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-574-6603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------