Provider Demographics
NPI:1841260346
Name:SHENANDOAH DOCTORS CLINIC
Entity type:Organization
Organization Name:SHENANDOAH DOCTORS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FURSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-246-1000
Mailing Address - Street 1:1 JACK FOSTER DR
Mailing Address - Street 2:SUITE #447
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-4586
Mailing Address - Country:US
Mailing Address - Phone:712-246-1000
Mailing Address - Fax:712-246-1050
Practice Address - Street 1:1 JACK FOSTER DR
Practice Address - Street 2:SUITE #447
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-4586
Practice Address - Country:US
Practice Address - Phone:712-246-1000
Practice Address - Fax:712-246-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33651261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3214536Medicaid
IA35131OtherMIDLANDS CHOICE
IA39007OtherWELLMARK
IAP00232672OtherRAILROAD MEDICARE
IA3214536Medicaid
IAP00232672OtherRAILROAD MEDICARE