Provider Demographics
NPI:1558413823
Name:ODEBOLT MEDICAL CLINIC
Entity Type:Organization
Organization Name:ODEBOLT MEDICAL CLINIC
Other - Org Name:SINNOTT & TOBEN MEDICAL ARTS, PLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELSE
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:712-668-2232
Mailing Address - Street 1:300 SOUTH MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:ODEBOLT
Mailing Address - State:IA
Mailing Address - Zip Code:51458
Mailing Address - Country:US
Mailing Address - Phone:712-668-2232
Mailing Address - Fax:712-668-2233
Practice Address - Street 1:300 SOUTH MAPLE STREET
Practice Address - Street 2:
Practice Address - City:ODEBOLT
Practice Address - State:IA
Practice Address - Zip Code:51458
Practice Address - Country:US
Practice Address - Phone:712-668-2232
Practice Address - Fax:712-668-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0143677Medicaid
IAX10895Medicare UPIN
IA0143677Medicaid