MEDICARE: MEDITELECARE OF IOWA PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	2084P0800X	Psychiatry Physician
3	2084P0805X	Geriatric Psychiatry Physician
4	363L00000X	Nurse Practitioner
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
6	103T00000X	Psychologist

General Provider Information

NPI Number	:	1386146678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDITELECARE OF IOWA PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1595
Second Line	:
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-8095
Country	:	US
Telephone Number	:	860-788-6404
Fax Number	:	860-829-0495

Provider Business Practice Location Address
First Line	:	400 E COURT AVE STE 110
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50309-2027
Country	:	US
Telephone Number	:	860-788-6404
Fax Number	:	860-829-0495

Authorized Official
Title or Position	:	CREDENTIALING & ENROLLMENT MANAGER
Name	:	ANDREA GODFREY
Credential	:
Telephone Number	:	860-398-6441

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	05/05/2025

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