1467447508 NPI number — BROADLAWNS MEDICAL CENTER

Table of content: (NPI 1467447508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467447508 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:
BROADLAWNS MEDICAL CENTER
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:
1467447508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 HICKMAN RD
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:
50314-1505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-282-2200
Provider Business Mailing Address Fax Number:
515-282-7823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 HICKMAN RD
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:
50314-1505
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:
515-282-7823
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MANDRACCHIA
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
515-282-2562

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  770032H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 770032H , 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: 0236471 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28545 . This is a "WELLMARK PROF CLINIC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 6S101 . This is a "WELLMARK INST PSYCH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0265959 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100020 . This is a "AMERICAN PYSCH SYSTMES" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 60101 . This is a "WELLMARK INSTITUTIONAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0432567 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26595 . This is a "WELLMARK PROF ED" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 29705 . This is a "CONVENTRY HEALTHCARE" 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: 20023 . This is a "TRICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 2601013 . This is a "HOSPITAL IOWA CARE NUMBER" 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".
  • Identifier: 0427476 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A5031401 . This is a "JOHN DEERE, UHC RIVER VAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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