NPIMap

Organization Active NPI

Country Clinic Medical Services Inc

Doing business as Country Clinic

  • Family Medicine Physician
  • Waukee, IA
National Provider Identifier
1396890158
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
02312 Issued in IA
Legal business name
COUNTRY CLINIC MEDICAL SERVICES INC
Doing business as
Country Clinic
Practice address
120 NE Dartmoor Dr
Waukee, IA 50263-9660
Phone
(515) 987-3117
Fax
(515) 987-3119
NPI assigned
Jan 24, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kim K Countryman, D.O.NPI 1750382347
Title
Owner
Phone
(515) 987-3117

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 02312 IA Primary

Addresses

Primary practice location

120 NE Dartmoor Dr
Waukee, IA 50263-9660

Mailing address

120 NE Dartmoor Dr
PO Box 968
Waukee, IA 50263-9660
Phone (515) 987-3117

Other identifiers 2

IdentifierTypeStateIssuer
1043646MedicaidIA
0284083MedicaidIA

Other names 1

  • Country Clinic Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169596800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1396890158",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 NE DARTMOOR DR",
            "address_2": "PO BOX 968",
            "city": "WAUKEE",
            "state": "IA",
            "postal_code": "502639660",
            "telephone_number": "515-987-3117",
            "fax_number": "515-987-3119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 NE DARTMOOR DR",
            "city": "WAUKEE",
            "state": "IA",
            "postal_code": "502639660",
            "telephone_number": "515-987-3117",
            "fax_number": "515-987-3119"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLINIC MEDICAL SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "COUNTRYMAN",
        "authorized_official_first_name": "KIM",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "515-987-3117",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IA",
            "license": "02312",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043646",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0284083",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waukee, IA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.