1700835865 NPI number — STATE UNIVERSITY OF IOWA

Table of content: (NPI 1700835865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700835865 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:
CENTERVILLE MEDICAL CLINIC
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:
1700835865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2941 SIERRA CT SW
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:
52240-8503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-337-7642
Provider Business Mailing Address Fax Number:
319-339-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19876 ST. JOSEPH DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-856-8684
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
319-384-2844

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA0044 . This is a "RR MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0280339 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33226 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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