Provider Demographics
| NPI: | 1164475760 |
|---|---|
| Name: | DES MOINES UNIVERSITY OSTEOPATHIC MEDICAL CENTER |
| Entity type: | Organization |
| Organization Name: | DES MOINES UNIVERSITY OSTEOPATHIC MEDICAL CENTER |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | ADMINISTRATOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | PHILIP |
| Authorized Official - Middle Name: | C |
| Authorized Official - Last Name: | BLUMBERG |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 515-271-1574 |
| Mailing Address - Street 1: | 3200 GRAND AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DES MOINES |
| Mailing Address - State: | IA |
| Mailing Address - Zip Code: | 50312-4104 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 515-471-9243 |
| Mailing Address - Fax: | 515-471-9319 |
| Practice Address - Street 1: | 3200 GRAND AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | DES MOINES |
| Practice Address - State: | IA |
| Practice Address - Zip Code: | 50312-4104 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 515-471-9243 |
| Practice Address - Fax: | 515-471-9319 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-18 |
| Last Update Date: | 2022-08-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 103TC0700X, 2084P0800X, 363A00000X | ||
| IA | 204D00000X, 207R00000X, 208100000X, 2085R0202X, 208D00000X, 213EP1101X, 213ES0103X, 225100000X, 225X00000X, 363A00000X, 207Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 204D00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 213EP1101X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | Group - Multi-Specialty |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IA | CQ2071 | Other | RR MEDICARE |
| IA | 0255182 | Medicaid | |
| IA | 0255166 | Medicaid | |
| 0311190001 | Medicare NSC | ||
| IA | 0255166 | Medicaid |
