Provider Demographics
NPI:1093790578
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:UNIVERSITY OF IOWA HOSPITALS & CLINICS-WASHINGTON DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR OF GOVERNMENT REIMB
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCKELVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:319-467-8549
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1616
Mailing Address - Fax:
Practice Address - Street 1:414 E POLK ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353-1237
Practice Address - Country:US
Practice Address - Phone:319-653-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-07
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0600585Medicaid
IA62306OtherWELLMARK BCBS
IA163510Medicare Oscar/Certification