Provider Demographics
NPI:1477554814
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:UNIVERSITY OF IOWA HOSPITALS & CLINICS/MEDICAL SERVICE PLAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDAELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-353-8162
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1616
Mailing Address - Fax:319-384-5164
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-356-1616
Practice Address - Fax:319-384-5164
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:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X, 207R00000X, 208000000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA004246Medicaid
IA33537OtherWELLMARK BCBS OF IA
IA004246Medicaid
ILIL2768Medicare PIN
IAI0923Medicare PIN
IACR0283Medicare PIN