1477554814 NPI number — STATE UNIVERSITY OF IOWA

Table of content: (NPI 1477554814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477554814 NPI number — STATE UNIVERSITY OF IOWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE UNIVERSITY OF IOWA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UNIVERSITY OF IOWA HOSPITALS & CLINICS/MEDICAL SERVICE PLAN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477554814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HAWKINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52242-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-356-1616
Provider Business Mailing Address Fax Number:
319-384-5164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-356-1616
Provider Business Practice Location Address Fax Number:
319-384-5164
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VANDAELE
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ASSOCIATE DEAN
Authorized Official Telephone Number:
319-353-8162

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004246 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33537 . This is a "WELLMARK BCBS OF IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 108788100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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