Basic Information
| Provider Information | |||||||||
| NPI: | 1669959573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UI HEALTHCARE SCOTT BLVD URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193397472 | ||||||||
| FaxNumber: | 3194677400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3640 MIDDLEBURY RD | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522452712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193397472 | ||||||||
| FaxNumber: | 3194677400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | BROOKS | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FOR MEDICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 3193358064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE UNIVERSITY OF IOWA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.