Provider Demographics
NPI:1043417637
Name:SOUTHERN IOWA GENERAL MEDICINE LLC
Entity Type:Organization
Organization Name:SOUTHERN IOWA GENERAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLESON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-237-3974
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:105 E MCLANE ST
Practice Address - Street 2:SUITE 400
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-1456
Practice Address - Country:US
Practice Address - Phone:641-342-6337
Practice Address - Fax:641-342-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400207Medicaid
IAG66532Medicare UPIN
IA0400207Medicaid