Provider Demographics
NPI:1336523893
Name:CONVENIENT CARE MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:CONVENIENT CARE MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAIN ASSISTANT/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:712-256-7172
Mailing Address - Street 1:3502 METRO DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-7724
Mailing Address - Country:US
Mailing Address - Phone:712-256-7172
Mailing Address - Fax:712-256-7374
Practice Address - Street 1:3502 METRO DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-7724
Practice Address - Country:US
Practice Address - Phone:712-256-7172
Practice Address - Fax:712-256-7374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002355363A00000X
IAA121973363L00000X
NE18737207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty