1851371561 NPI number — STATE UNIVERSITY OF IOWA

Table of content: (NPI 1851371561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851371561 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:
STATE HYGIENIC LABORATORY AT THE UNIVERSITY OF IOWA
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:
1851371561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2490 CROSSPARK RD
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:
52241-4721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-335-4500
Provider Business Mailing Address Fax Number:
319-335-4171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2490 CROSSPARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241-4721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-335-4500
Provider Business Practice Location Address Fax Number:
319-335-4171
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALSOUS
Authorized Official First Name:
WADE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CLINIC LAB DIRECTO
Authorized Official Telephone Number:
319-335-4500

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  NONE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 410567200 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0680447 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200394010A , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17010 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32906000 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 703280602 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WELLMARK . This is a "WELLMARK INSURANCE #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 5580770 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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