Basic Information
| Provider Information | |||||||||
| NPI: | 1376544320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY OF IOWA HOSPITALS & CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193561616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193561616 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | BROOKS | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR MEDICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 3193358064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 520017H | IA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0600585 | 05 | IA | MEDICAID | 60058 | 01 | IA | WELLMARK BC/BS | OTHER | 054878006 | 01 | IA | MEDICARE DME NUMBER | OTHER |