Provider Demographics
NPI:1992023642
Name:FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIEDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:712-754-2900
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:SIBLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51249-0277
Mailing Address - Country:US
Mailing Address - Phone:712-754-2900
Mailing Address - Fax:712-754-2634
Practice Address - Street 1:600 9TH AVE N
Practice Address - Street 2:
Practice Address - City:SIBLEY
Practice Address - State:IA
Practice Address - Zip Code:51249-1012
Practice Address - Country:US
Practice Address - Phone:712-754-2900
Practice Address - Fax:712-754-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty