Provider Demographics
NPI:1285635664
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:STUDENT HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR STUDENT HEALTH SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-384-1135
Mailing Address - Street 1:4189 WL UNIVERSITY OF IOWA
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1100
Mailing Address - Country:US
Mailing Address - Phone:319-335-8376
Mailing Address - Fax:319-335-7247
Practice Address - Street 1:4189 WL UNIVERSITY OF IOWA
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1100
Practice Address - Country:US
Practice Address - Phone:319-335-8376
Practice Address - Fax:319-335-7247
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0089771Medicaid
IA08977OtherWELLMARK BC/BS
IA0089771Medicaid