Provider Demographics
NPI:1285005850
Name:IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/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 1:600 N COLLEGE AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1095
Mailing Address - Country:US
Mailing Address - Phone:309-944-5342
Mailing Address - Fax:309-945-4079
Practice Address - Street 1:600 N COLLEGE AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1095
Practice Address - Country:US
Practice Address - Phone:309-944-5342
Practice Address - Fax:309-945-4079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty