Basic Information
| Provider Information | |||||||||
| NPI: | 1588674675 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POLK COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | POLK COUNTY HEALTH DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1907 CARPENTER AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503141310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152863798 | ||||||||
| FaxNumber: | 5152862033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOZIN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5152863759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 0447615 | 05 | IA | MEDICAID |