Provider Demographics
NPI:1487731402
Name:PRACTICE OF FAMILY MEDICINE, P.C.
Entity type:Organization
Organization Name:PRACTICE OF FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:LOUVAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:319-395-7878
Mailing Address - Street 1:1515 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3061
Mailing Address - Country:US
Mailing Address - Phone:319-395-7878
Mailing Address - Fax:319-395-7898
Practice Address - Street 1:1515 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3061
Practice Address - Country:US
Practice Address - Phone:319-395-7878
Practice Address - Fax:319-395-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1487731402OtherMEDICARE B
IA49757OtherBLUE CROSS BLUE SHIELD IA
IA12493OtherMIDLANDS
5336687OtherAETNA
179301OtherJOHN DEERE HEALTH CARE
IA0400454Medicaid
A00808OtherUPIN
0000OtherCHAMPUS
=========OtherTIN