Provider Demographics
NPI:1558340968
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:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:319-768-5858
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 1:400 N 17TH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3452
Practice Address - Country:US
Practice Address - Phone:319-524-5734
Practice Address - Fax:319-524-5758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33624OtherBLUE CROSS BLUE SHIELD
IA0278374Medicaid
MO506089408Medicaid
IL=========003Medicaid
IA33624OtherBLUE CROSS BLUE SHIELD
=========OtherTRICARE
MO506089408Medicaid
IA0278374Medicaid
IAI7904Medicare PIN