Provider Demographics
NPI:1700834298
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:UI FAMILY CARE WAPELLO
Other - Org Type:Doing Business As
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 N 2ND ST
Practice Address - Street 2:
Practice Address - City:WAPELLO
Practice Address - State:IA
Practice Address - Zip Code:52653-1202
Practice Address - Country:US
Practice Address - Phone:319-523-8205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0175455Medicaid
IACG4344OtherRR MEDICARE
IACG4344OtherRR MEDICARE