Provider Demographics
NPI:1396768503
Name:UNDERWOOD FAMILY PRACTICE
Entity type:Organization
Organization Name:UNDERWOOD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:OGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-566-9148
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51576-0218
Mailing Address - Country:US
Mailing Address - Phone:712-566-9148
Mailing Address - Fax:712-566-9408
Practice Address - Street 1:401 HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:IA
Practice Address - Zip Code:51576-5030
Practice Address - Country:US
Practice Address - Phone:712-566-9148
Practice Address - Fax:712-566-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-082459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA082459Medicare ID - Type UnspecifiedMEDICARE NUMBER
IAS61518Medicare UPIN