Basic Information
| Provider Information | |||||||||
| NPI: | 1992737258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL IOWA HOSPITAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1440 PLEASANT STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503141728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154719243 | ||||||||
| FaxNumber: | 5154719319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 PLEASANT STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503141728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153096011 | ||||||||
| FaxNumber: | 5153096014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEWERFF | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5152416507 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL IOWA HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0234112 | 05 | IA | MEDICAID |