Basic Information
Provider Information | |||||||||
NPI: | 1407381031 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITYPOINT HEALTH - MARSHALLTOWN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNITYPOINT HEALTH - FAMILY MEDICINE CLINIC - STATE CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 UNITYPOINT WAY | ||||||||
Address2: |   | ||||||||
City: | MARSHALLTOWN | ||||||||
State: | IA | ||||||||
PostalCode: | 501584749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6417545145 | ||||||||
FaxNumber: | 6418446208 | ||||||||
Practice Location | |||||||||
Address1: | 503 3RD AVE SW | ||||||||
Address2: |   | ||||||||
City: | STATE CENTER | ||||||||
State: | IA | ||||||||
PostalCode: | 502477719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6418442970 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2017 | ||||||||
LastUpdateDate: | 04/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DELAGARDELLE | ||||||||
AuthorizedOfficialFirstName: | PAMELA | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3192353606 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNITYPOINT HEALTH - MARSHALLTOWN | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.