Healthcare Provider Details

I. General information

NPI: 1962453274
Provider Name (Legal Business Name): STADIA SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 UNIVERSITY AVE SUITE 250
WEST DES MOINES IA
50266-8203
US

IV. Provider business mailing address

6000 UNIVERSITY AVE SUITE 250
WEST DES MOINES IA
50266
US

V. Phone/Fax

Practice location:
  • Phone: 515-221-1102
  • Fax: 515-221-1272
Mailing address:
  • Phone: 515-221-1102
  • Fax: 515-221-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number36501
License Number StateIA

VIII. Authorized Official

Name: DR. CHAD THOMAS CARLSON
Title or Position: CEO, STADIA SPORTS MEDICINE
Credential: M.D.
Phone: 515-221-1102