Provider Demographics
NPI:1962453274
Name:STADIA SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:STADIA SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, STADIA SPORTS MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-221-1102
Mailing Address - Street 1:6000 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266
Mailing Address - Country:US
Mailing Address - Phone:515-221-1102
Mailing Address - Fax:515-221-1272
Practice Address - Street 1:6000 UNIVERSITY AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8203
Practice Address - Country:US
Practice Address - Phone:515-221-1102
Practice Address - Fax:515-221-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36501204C00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty