Basic Information
| Provider Information | |||||||||
| NPI: | 1700835865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
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| OtherOrganizationName: | CENTERVILLE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2941 SIERRA CT SW | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522408503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193377642 | ||||||||
| FaxNumber: | 3193391449 | ||||||||
| Practice Location | |||||||||
| Address1: | 19876 ST. JOSEPH DRIVE | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418568684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3193842844 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DA0044 | 01 | IA | RR MEDICARE | OTHER | 0280339 | 05 | IA | MEDICAID | 33226 | 01 | IA | WELLMARK | OTHER |