Provider Demographics
NPI:1326078130
Name:COUNTRY DOCTOR PC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRODALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:641-664-1799
Mailing Address - Street 1:18754 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-6803
Mailing Address - Country:US
Mailing Address - Phone:641-664-1799
Mailing Address - Fax:641-664-1663
Practice Address - Street 1:18754 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-6803
Practice Address - Country:US
Practice Address - Phone:641-664-1799
Practice Address - Fax:641-664-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3485204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209029206Medicaid
IA2424325Medicaid
MO209029206Medicaid
MO209029206Medicaid