Provider Demographics
NPI:1972357325
Name:MOUNT VERNON FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:MOUNT VERNON FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA B
Authorized Official - Middle Name:B
Authorized Official - Last Name:AXDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-253-5291
Mailing Address - Street 1:107 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1422
Mailing Address - Country:US
Mailing Address - Phone:319-895-1620
Mailing Address - Fax:319-895-1250
Practice Address - Street 1:107 1ST ST NE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1422
Practice Address - Country:US
Practice Address - Phone:319-361-5815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-12
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service