Basic Information
| Provider Information | |||||||||
| NPI: | 1336107283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IOWA RADIOLOGY, P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12368 STRATFORD DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152269810 | ||||||||
| FaxNumber: | 5152268408 | ||||||||
| Practice Location | |||||||||
| Address1: | 12368 STRATFORD DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152269810 | ||||||||
| FaxNumber: | 5152268408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHEPHERD | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5152267426 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0230813 | 05 | IA | MEDICAID |