Provider Demographics
NPI:1225177579
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:CHSC PED SCREENING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, PATIENT FINANCIAL SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROUDABUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-384-2334
Mailing Address - Street 1:100 HAWKINS DRIVE
Mailing Address - Street 2:CHILD HEALTH SPECIALTY CLINICS
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242
Mailing Address - Country:US
Mailing Address - Phone:319-354-6674
Mailing Address - Fax:319-356-3715
Practice Address - Street 1:3501 HARRY LANGDON BLVD STE 1450
Practice Address - Street 2:CHILD HEALTH SPECIALTY CLINICS
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-7837
Practice Address - Country:US
Practice Address - Phone:712-309-0041
Practice Address - Fax:712-309-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0734871Medicaid