Provider Demographics
NPI:1902868664
Name:CHARITON VALLEY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:CHARITON VALLEY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-437-4344
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:707 S MAIN
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-2421
Mailing Address - Country:US
Mailing Address - Phone:641-437-4344
Mailing Address - Fax:641-856-5410
Practice Address - Street 1:707 S MAIN
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-2421
Practice Address - Country:US
Practice Address - Phone:641-437-4344
Practice Address - Fax:641-856-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17554207Q00000X
IA30574207Q00000X
IA01603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3130443Medicaid
IA0024141Medicaid
IA1110031Medicaid
IA0024141Medicaid
IA3130443Medicaid
F96822Medicare UPIN
A01157Medicare UPIN
A00013Medicare UPIN
IAI2104Medicare ID - Type Unspecified