Basic Information
Provider Information | |||||||||
NPI: | 1578631826 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEAY | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 411 LAUREL STREET | ||||||||
Address2: | SUITE 3170 | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 50314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152830463 | ||||||||
FaxNumber: | 5152830794 | ||||||||
Practice Location | |||||||||
Address1: | 411 LAUREL STREET | ||||||||
Address2: | SUITE 3170 | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 50314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152830463 | ||||||||
FaxNumber: | 5152830794 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2006 | ||||||||
LastUpdateDate: | 12/31/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 27486 | IA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 0064600 | 05 | IA |   | MEDICAID |