Provider Demographics
NPI:1386665461
Name:FAMILY & SPECIALTY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:FAMILY & SPECIALTY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DANETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-792-4000
Mailing Address - Street 1:515 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2739
Mailing Address - Country:US
Mailing Address - Phone:712-792-4000
Mailing Address - Fax:712-792-7773
Practice Address - Street 1:515 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2739
Practice Address - Country:US
Practice Address - Phone:712-792-4000
Practice Address - Fax:712-792-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
IA3267207Q00000X
IA02754225100000X
IA000745363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IACH4508OtherRAILROAD MEDICARE GROUP #
IACH4508OtherRAILROAD MEDICARE GROUP #