1922089002 NPI number — BROADLAWNS MEDICAL CENTER

Table of content: (NPI 1922089002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922089002 NPI number — BROADLAWNS MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADLAWNS MEDICAL CENTER
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:
SANDS MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
5
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:
1922089002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/09/2007
NPI Reactivation Date:
04/03/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 HICKMAN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-282-2200
Provider Business Mailing Address Fax Number:
515-282-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 HICKMAN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-282-2200
Provider Business Practice Location Address Fax Number:
515-282-3234
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JENNER
Authorized Official First Name:
JODY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
515-282-2234

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A5031401 . This is a "JOHN DEERE, UHC RIVER VAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0601013 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132198 . This is a "VALUE OPTIONS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 29705 . This is a "COVENTRY" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 10020 . This is a "AMERICAN PSYCH SYSTEMS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 20023 . This is a "TRICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 6230290 . This is a "AETNA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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