Provider Demographics
NPI:1962047522
Name:STATE UNIVERSITY OF IOWA
Entity type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDAELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-353-8162
Mailing Address - Street 1:2591 HOLIDAY RD
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-3039
Mailing Address - Country:US
Mailing Address - Phone:319-356-3335
Mailing Address - Fax:319-467-7181
Practice Address - Street 1:2591 HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-3039
Practice Address - Country:US
Practice Address - Phone:319-356-3335
Practice Address - Fax:319-467-7181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE UNIVERSITY OF IOWA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-07
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine