Provider Demographics
NPI:1538364310
Name:EXIRA FAMILY MEDICINE CLINIC, LLC
Entity type:Organization
Organization Name:EXIRA FAMILY MEDICINE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:712-268-5348
Mailing Address - Street 1:107 S JEFFERSON ST
Mailing Address - Street 2:PO BOX 87
Mailing Address - City:EXIRA
Mailing Address - State:IA
Mailing Address - Zip Code:50076-7726
Mailing Address - Country:US
Mailing Address - Phone:712-268-5348
Mailing Address - Fax:712-268-2145
Practice Address - Street 1:107 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:EXIRA
Practice Address - State:IA
Practice Address - Zip Code:50076-7726
Practice Address - Country:US
Practice Address - Phone:712-268-5348
Practice Address - Fax:712-268-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0455311Medicaid
IAD46549Medicare UPIN
IA0455311Medicaid