MEDICARE: STATE UNIVERSITY OF IOWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1548526189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE UNIVERSITY OF IOWA

Provider Business Mailing Address
First Line	:	200 HAWKINS DR
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52242-1009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	767 MORMON TREK BLVD
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52246-1812
Country	:	US
Telephone Number	:	319-384-8333
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, PATIENT FINANCIAL SERVICE
Name	:	PHILIP E ROUDABUSH
Credential	:
Telephone Number	:	318-384-2334

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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Directions to “STATE UNIVERSITY OF IOWA ” Practice Location

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