Basic Information
| Provider Information | |||||||||
| NPI: | 1508281205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IOWA DIAGNOSTIC IMAGING & PROCEDURE L C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRAL IOWA HOSPITAL CORP MEMBER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502665945 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4200 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502665945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159610453 | ||||||||
| FaxNumber: | 5159612714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TIEDEMANN | ||||||||
| AuthorizedOfficialFirstName: | CHERI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5159610453 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2073326 | 05 | IA | MEDICAID |