Provider Demographics
NPI:1851371561
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:STATE HYGIENIC LABORATORY AT THE UNIVERSITY OF IOWA
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC LAB DIRECTO
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ALSOUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:319-335-4500
Mailing Address - Street 1:2490 CROSSPARK RD
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-4721
Mailing Address - Country:US
Mailing Address - Phone:319-335-4500
Mailing Address - Fax:319-335-4171
Practice Address - Street 1:2490 CROSSPARK RD
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-4721
Practice Address - Country:US
Practice Address - Phone:319-335-4500
Practice Address - Fax:319-335-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA410567200Medicaid
IA0680447Medicaid
IA200394010AMedicaid
IA17010Medicaid
IA32906000Medicaid
IA703280602Medicaid
IAWELLMARKOtherWELLMARK INSURANCE #
IA5580770Medicaid
IAWELLMARKOtherWELLMARK INSURANCE #