1811043326 NPI number — MIDWEST AMBUCARE

Table of content: (NPI 1811043326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811043326 NPI number — MIDWEST AMBUCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST AMBUCARE
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:
1811043326
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2535 106TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50322-3766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-252-1721
Provider Business Mailing Address Fax Number:
515-252-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 KEOSAUQUA WAY
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:
50309-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-244-0409
Provider Business Practice Location Address Fax Number:
515-243-4932
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAPMAN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
515-252-1721

Provider Taxonomy Codes

  • Taxonomy code: 344600000X , with the licence number:  06-38844 , 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: 0234005 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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