Provider Demographics
NPI:1265433676
Name:STATE UNIVERSITY OF IOWA
Entity type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEAD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-384-9609
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:C660 GH
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-9647
Mailing Address - Fax:319-384-5184
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:C660 GH
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-9647
Practice Address - Fax:319-384-5184
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-09
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16D0664625291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33898OtherWELLMARK BC/BS
IA0291393Medicaid
IA0291393Medicaid
IACD2493Medicare PIN