Provider Demographics
NPI: | 1164475760 |
---|---|
Name: | DES MOINES UNIVERSITY OSTEOPATHIC MEDICAL CENTER |
Entity Type: | Organization |
Organization Name: | DES MOINES UNIVERSITY OSTEOPATHIC MEDICAL CENTER |
Other - Org Name: | DES MOINES UNIVERSITY CLINIC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | PHILIP |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | BLUMBERG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 515-271-1574 |
Mailing Address - Street 1: | 3200 GRAND AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | DES MOINES |
Mailing Address - State: | IA |
Mailing Address - Zip Code: | 50312-4104 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 515-471-9243 |
Mailing Address - Fax: | 515-471-9319 |
Practice Address - Street 1: | 3200 GRAND AVE |
Practice Address - Street 2: | |
Practice Address - City: | DES MOINES |
Practice Address - State: | IA |
Practice Address - Zip Code: | 50312-4104 |
Practice Address - Country: | US |
Practice Address - Phone: | 515-471-9243 |
Practice Address - Fax: | 515-471-9319 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-18 |
Last Update Date: | 2022-08-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103TC0700X, 2084P0800X, 363A00000X | ||
IA | 204D00000X, 207Q00000X, 207R00000X, 208100000X, 2085R0202X, 208D00000X, 213EP1101X, 213ES0103X, 225100000X, 225X00000X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 204D00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 213EP1101X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | Group - Multi-Specialty |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IA | CQ2071 | Other | RR MEDICARE |
IA | 0255182 | Medicaid | |
IA | 0255166 | Medicaid | |
0311190001 | Medicare NSC | ||
IA | 0255166 | Medicaid |