Provider Demographics
NPI:1326085739
Name:FREDERICKSBURG FAMILY HEALTH CLINIC
Entity Type:Organization
Organization Name:FREDERICKSBURG FAMILY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:PERAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-237-5316
Mailing Address - Street 1:115 SCHULT RIDGE RD
Mailing Address - Street 2:PO BOX 335
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:IA
Mailing Address - Zip Code:50630-9582
Mailing Address - Country:US
Mailing Address - Phone:563-237-5316
Mailing Address - Fax:563-237-6337
Practice Address - Street 1:115 SCHULT RIDGE RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:IA
Practice Address - Zip Code:50630-9582
Practice Address - Country:US
Practice Address - Phone:563-237-5316
Practice Address - Fax:563-237-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13040OtherBCBS
IA0130401Medicaid
IA16D0384603OtherCLIA#
IAA004550OtherTRICARE PROV.#
IA0130401Medicaid
IAA004550OtherTRICARE PROV.#