Basic Information
Provider Information | |||||||||
NPI: | 1750371373 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE IOWA CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RADIOLOGY DEPARTMENT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6800 LAKE DRIVE | ||||||||
Address2: | STE 250 | ||||||||
City: | WEST DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 502662504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5158759925 | ||||||||
FaxNumber: | 5158759923 | ||||||||
Practice Location | |||||||||
Address1: | 1221 PLEASANT ST | ||||||||
Address2: | STE 150 | ||||||||
City: | DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 503091423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152445109 | ||||||||
FaxNumber: | 5152413505 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2005 | ||||||||
LastUpdateDate: | 09/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | EDWARD | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5158759100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CEO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.