Basic Information
| Provider Information | |||||||||
| NPI: | 1710988761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE UNIVERSITY OF IOWA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY OF IOWA HOSPITALS & CLINICS/AIR & MOBILE CRITICAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DRIVE | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193536360 | ||||||||
| FaxNumber: | 3193849184 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DRIVE | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193536360 | ||||||||
| FaxNumber: | 3193849184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NUGENT | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3193536360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE UNIVERSITY OF IOWA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 8000100 | IA | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 60058 | 01 | IA | WELLMARK BCBS | OTHER | 0231837 | 05 | IA | MEDICAID |