Healthcare Provider Details

I. General information

NPI: 1992037865
Provider Name (Legal Business Name): STATE UNIVERSITY OF IOWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 RIVER CROSSING COURT
RIVERSIDE IA
52327-4727
US

IV. Provider business mailing address

200 HAWKINS DR
IOWA CITY IA
52242-1007
US

V. Phone/Fax

Practice location:
  • Phone: 319-467-8355
  • Fax: 319-467-8351
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PHILIP E ROUDABUSH
Title or Position: DIRECTOR, PATIENT FINANCIAL SERVICE
Credential:
Phone: 319-384-2334