Basic Information
| Provider Information | |||||||||
| NPI: | 1275048217 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
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| OtherOrganizationName: | UIHC AUDIOLOGIST GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193562222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193562222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2017 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | GANTZ | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MD, SUPERVISING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3193562173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE UNIVERSITY OF IOWA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.