Provider Demographics
NPI:1164483491
Name:COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA INC
Other - Org Name:TRI-STATE MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD BILLING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SCHNEDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-5809
Mailing Address - Street 1:1706 WEST AGENCY ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655
Mailing Address - Country:US
Mailing Address - Phone:319-768-5858
Mailing Address - Fax:319-753-2301
Practice Address - Street 1:1425 MORGAN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-4027
Practice Address - Country:US
Practice Address - Phone:217-256-3013
Practice Address - Fax:319-753-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33624OtherBLUE CROSS BLUE SHIELD
IA0786558Medicaid
MO506089440Medicaid
IA33624OtherBLUE CROSS BLUE SHIELD
=========OtherAETNA
=========OtherTRICARE
MO506089440Medicaid
IA0786558Medicaid
MO506089440Medicaid