Basic Information
| Provider Information | |||||||||
| NPI: | 1063802791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
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| OtherOrganizationName: | UNIVERSITY OF IOWA CHILDREN'S HOSPITAL GEN PEDIATRICS-NORTH LIBERTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1765 LININGER LN | ||||||||
| Address2: | |||||||||
| City: | NORTH LIBERTY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 523172316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194677888 | ||||||||
| FaxNumber: | 3194677889 | ||||||||
| Practice Location | |||||||||
| Address1: | 1765 LININGER LN | ||||||||
| Address2: | |||||||||
| City: | NORTH LIBERTY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 523172316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194677888 | ||||||||
| FaxNumber: | 3194677889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROUDABUSH | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PATIENT FINANCIAL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 3193842334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.