Provider Demographics
NPI:1205040557
Name:COVENANT MEDICAL CENTER INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PANICUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-272-7300
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:319-272-7600
Mailing Address - Fax:319-272-7597
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-7600
Practice Address - Fax:319-272-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0063271Medicaid