Provider Demographics
NPI:1114974961
Name:DES MOINES INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:DES MOINES INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRIER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-243-1180
Mailing Address - Street 1:1300 WALNUT ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-3401
Mailing Address - Country:US
Mailing Address - Phone:515-243-1180
Mailing Address - Fax:515-243-1461
Practice Address - Street 1:1300 WALNUT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3401
Practice Address - Country:US
Practice Address - Phone:515-243-1180
Practice Address - Fax:515-243-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0476184Medicaid
IAI8751Medicare ID - Type UnspecifiedMEDICARE GROUP #