Provider Demographics
NPI:1063465003
Name:NORTHWEST IOWA UROLOGISTS PC
Entity Type:Organization
Organization Name:NORTHWEST IOWA UROLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:MENDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-262-6214
Mailing Address - Street 1:1200 1ST AVE E
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4342
Mailing Address - Country:US
Mailing Address - Phone:712-262-6214
Mailing Address - Fax:712-262-6216
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:SUITE B
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-262-6214
Practice Address - Fax:712-262-6216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20168174400000X, 332B00000X
IA24150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0183244Medicaid
IACH00011Medicare PIN
IACP8558Medicare PIN
IA18324Medicare PIN