Provider Demographics
NPI:1962485136
Name:CENTRAL IOWA HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CENTRAL IOWA HOSPITAL CORPORATION
Other - Org Name:PATHOLOGY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-241-6507
Mailing Address - Street 1:3001 SE CONVENIENCE BLVD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-8503
Mailing Address - Country:US
Mailing Address - Phone:515-241-8878
Mailing Address - Fax:515-241-8857
Practice Address - Street 1:3001 SE CONVENIENCE BLVD UNIT 104
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-8503
Practice Address - Country:US
Practice Address - Phone:515-241-8878
Practice Address - Fax:515-241-8857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16D0383397291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0198945Medicaid
IA05709Medicare ID - Type UnspecifiedPROVIDER NUMBER