Active NPI
State University of Iowa
- Family Medicine Physician
- Centerville, IA
National Provider Identifier
1700835865
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- STATE UNIVERSITY OF IOWA
- Doing business as
- Centerville Medical Clinic
- Practice address
- 19876 St. Joseph Drive
Centerville, IA 52544 - Phone
- (641) 856-8684
- NPI assigned
- May 8, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Kenneth L Fisher
- Title
- Cfo
- Phone
- (319) 384-2844
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary |
Addresses
Primary practice location
19876 St. Joseph Drive
Centerville, IA 52544
Mailing address
2941 Sierra CT SW
Iowa City, IA 52240-8503
Phone (319) 337-7642
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DA0044 | Other | IA | RR MEDICARE |
| 0280339 | Medicaid | IA | |
| 33226 | Other | IA | WELLMARK |
Other names 1
- Centerville Medical Clinic
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031107000060 | IA | Part B Supplier - Clinic/Group Practice | 7618884230 |
Receives reassigned benefits from 2,348 practitioners 37 other NPIs on this enrollment This NPI is an additional NPI on the enrollment |
Other NPIs on the same Medicare enrollment 36
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
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- Washington, IA
- NPI 1093790578
O20031107000060
-
- Plastic and Reconstructive Surgery Physician
- Cedar Rapids, IA
- NPI 1114390358
O20031107000060
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147046400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1246924800000",
"number": "1700835865",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2941 SIERRA CT SW",
"city": "IOWA CITY",
"state": "IA",
"postal_code": "522408503",
"telephone_number": "319-337-7642",
"fax_number": "319-339-1449"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "19876 ST. JOSEPH DRIVE",
"city": "CENTERVILLE",
"state": "IA",
"postal_code": "52544",
"telephone_number": "641-856-8684"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "STATE UNIVERSITY OF IOWA",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-08",
"last_updated": "2009-07-07",
"status": "A",
"authorized_official_last_name": "FISHER",
"authorized_official_first_name": "KENNETH",
"authorized_official_middle_name": "L",
"authorized_official_title_or_position": "CFO",
"authorized_official_telephone_number": "319-384-2844"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RR MEDICARE",
"identifier": "DA0044",
"state": "IA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0280339",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WELLMARK",
"identifier": "33226",
"state": "IA"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Centerville Medical Clinic",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Centerville, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.