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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  Y SuppliersDurable Medical Equipment & Medical Supplies 

No ID Information.


Home