Provider Demographics
NPI:1467447508
Name:BROADLAWNS MEDICAL CENTER
Entity Type:Organization
Organization Name:BROADLAWNS MEDICAL CENTER
Other - Org Name:BROADLAWNS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANDRACCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:515-282-2562
Mailing Address - Street 1:1801 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1505
Mailing Address - Country:US
Mailing Address - Phone:515-282-2200
Mailing Address - Fax:515-282-7823
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1505
Practice Address - Country:US
Practice Address - Phone:515-282-2200
Practice Address - Fax:515-282-7823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA770032H273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0236471Medicaid
IA28545OtherWELLMARK PROF CLINIC
IA6S101OtherWELLMARK INST PSYCH
IA0265959Medicaid
IA100020OtherAMERICAN PYSCH SYSTMES
IA60101OtherWELLMARK INSTITUTIONAL
IA0432567Medicaid
IA26595OtherWELLMARK PROF ED
IA29705OtherCONVENTRY HEALTHCARE
IA0601013Medicaid
IA132198OtherVALUE OPTIONS
IA20023OtherTRICARE
IA2601013OtherHOSPITAL IOWA CARE NUMBER
IA6230290OtherAETNA
IA0427476Medicaid
IAA5031401OtherJOHN DEERE, UHC RIVER VAL
IA29705OtherCONVENTRY HEALTHCARE
IA2601013OtherHOSPITAL IOWA CARE NUMBER
IA28545OtherWELLMARK PROF CLINIC