Provider Demographics
NPI:1124026489
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:WILLIAM
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-754-3658
Mailing Address - Street 1:600 9TH AVE N
Mailing Address - Street 2:PO BOX 277
Mailing Address - City:SIBLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51249-1012
Mailing Address - Country:US
Mailing Address - Phone:712-754-3658
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:712-754-3658
Practice Address - Fax:712-754-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18374207QG0300X, 207QS0010X, 207Q00000X
IA18381207Q00000X
IA02364207Q00000X
IA02096207Q00000X
IA3511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0087106Medicaid
MN626810200Medicaid
MN115341OtherMINNESOTA UCARE
MN115341OtherMINNESOTA UCARE