Provider Demographics
NPI:1396890158
Name:COUNTRY CLINIC MEDICAL SERVICES INC
Entity type:Organization
Organization Name:COUNTRY CLINIC MEDICAL SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:K
Authorized Official - Last Name:COUNTRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:515-987-3117
Mailing Address - Street 1:120 NE DARTMOOR DR
Mailing Address - Street 2:PO BOX 968
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-9660
Mailing Address - Country:US
Mailing Address - Phone:515-987-3117
Mailing Address - Fax:515-987-3119
Practice Address - Street 1:120 NE DARTMOOR DR
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-9660
Practice Address - Country:US
Practice Address - Phone:515-987-3117
Practice Address - Fax:515-987-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0284083Medicaid
IA1043646Medicaid
IAI8871Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IAI8874Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER
IA1043646Medicaid
IA0284083Medicaid