Provider Demographics
NPI:1699880138
Name:AFFILIATES OF FAMILY PRACTICE OF CEDAR RAPIDS
Entity type:Organization
Organization Name:AFFILIATES OF FAMILY PRACTICE OF CEDAR RAPIDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:CEARLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-364-7730
Mailing Address - Street 1:1030 5TH AVENUE SE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403
Mailing Address - Country:US
Mailing Address - Phone:319-364-7730
Mailing Address - Fax:319-364-0240
Practice Address - Street 1:1030 5TH AVENUE SE
Practice Address - Street 2:SUITE 1700
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403
Practice Address - Country:US
Practice Address - Phone:319-364-7730
Practice Address - Fax:319-364-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22198207Q00000X
IA34383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0253740Medicaid
IA0253740Medicaid
IAI9335Medicare ID - Type Unspecified