Basic Information
| Provider Information | |||||||||
| NPI: | 1295064111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS CLINIC OF IOWA, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IOWA BLOOD AND CANCER CARE OF PCI MEDICATION DISPENSING SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3178 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524063178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193992096 | ||||||||
| FaxNumber: | 3193992036 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 10TH ST SE | ||||||||
| Address2: | DEPT OF HEMATOLOGY & ONCOLOGY | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524032404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192972900 | ||||||||
| FaxNumber: | 3192972969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2009 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | SPARENBORG | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3192473003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS' CLINIC OF IOWA, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | 1477682540 | IA | Y | Suppliers | Pharmacy | Specialty Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 16D1079312 | 01 | IA | CLIA | OTHER |