1619057361 NPI number — PULMONARY ASSOCIATES OF IOWA CITY, PC

Table of content: (NPI 1619057361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619057361 NPI number — PULMONARY ASSOCIATES OF IOWA CITY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PULMONARY ASSOCIATES OF IOWA CITY, PC
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:
Provider Other Organization Name Type Code:
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:
1619057361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 CROSSPARK RD STE W230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORALVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52241-4710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-887-2873
Provider Business Mailing Address Fax Number:
319-887-2870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52245-2477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-887-2873
Provider Business Practice Location Address Fax Number:
319-887-2870
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOY
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
319-887-2873

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  27094 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39714 . This is a "WELLMARK/ BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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