Provider Demographics
NPI:1922089002
Name:BROADLAWNS MEDICAL CENTER
Entity Type:Organization
Organization Name:BROADLAWNS MEDICAL CENTER
Other - Org Name:SANDS MENTAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-282-2234
Mailing Address - Street 1:1801 HICKMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314
Mailing Address - Country:US
Mailing Address - Phone:515-282-2200
Mailing Address - Fax:515-282-3234
Practice Address - Street 1:1801 HICKMAN ROAD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314
Practice Address - Country:US
Practice Address - Phone:515-282-2200
Practice Address - Fax:515-282-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2008-04-03
Deactivation Date:2007-11-09
Deactivation Code:
Reactivation Date:2008-04-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA5031401OtherJOHN DEERE, UHC RIVER VAL
IA0601013Medicaid
IA132198OtherVALUE OPTIONS
IA29705OtherCOVENTRY
IA10020OtherAMERICAN PSYCH SYSTEMS
IA20023OtherTRICARE
IA6230290OtherAETNA
IA16S101Medicare ID - Type Unspecified