Basic Information
| Provider Information | |||||||||
| NPI: | 1568599314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL IOWA HOSPITAL CORP. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLANK HEALTH PROVIDERS NP GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 PLEASANT ST. | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415926 | ||||||||
| FaxNumber: | 5152415127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 PLEASANT ST. | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415926 | ||||||||
| FaxNumber: | 5152415127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATTON-QUIGLEY | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5152416447 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CAPPM, MCPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 073850 | 05 | IA | MEDICAID | 0738500 | 05 | IA | MEDICAID |