Provider Demographics
NPI:1063448462
Name:IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Other - Org Name:TRINITY FAMILY MED ASSOC CAMBRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-471-9227
Mailing Address - Street 1:8101 BIRCHWOOD COURT
Mailing Address - Street 2:SUITE R
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2930
Mailing Address - Country:US
Mailing Address - Phone:515-471-9243
Mailing Address - Fax:515-471-9319
Practice Address - Street 1:106 N EAST ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:IL
Practice Address - Zip Code:61238-1157
Practice Address - Country:US
Practice Address - Phone:309-937-2405
Practice Address - Fax:309-937-5228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1100240061Medicare NSC