Provider Demographics
NPI:1700835865
Name:STATE UNIVERSITY OF IOWA
Entity Type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:CENTERVILLE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-384-2844
Mailing Address - Street 1:2941 SIERRA CT SW
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-8503
Mailing Address - Country:US
Mailing Address - Phone:319-337-7642
Mailing Address - Fax:319-339-1449
Practice Address - Street 1:19876 ST. JOSEPH DRIVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544
Practice Address - Country:US
Practice Address - Phone:641-856-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADA0044OtherRR MEDICARE
IA0280339Medicaid
IA33226OtherWELLMARK
IA0280339Medicaid