Basic Information
| Provider Information | |||||||||
| NPI: | 1376539601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAREW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193849506 | ||||||||
| FaxNumber: | 3193847899 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193849506 | ||||||||
| FaxNumber: | 3193847899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21717 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 21717 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 56181 | 01 | IA | WELLMARK BCBS | OTHER | 1207217 | 05 | IA | MEDICAID |