Organization
STATE UNIVERSITY OF IOWA
Active
Other names
Centerville Medical Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
KENNETH L FISHER (CFO)
(319) 384-2844
Entity
Organization
Contact information
Practice address
19876 ST. JOSEPH DRIVE, CENTERVILLE, IA 52544
(641) 856-8684
Mailing address
2941 SIERRA CT SW, IOWA CITY, IA 52240-8503
(319) 337-7642
(319) 339-1449
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0280339
—
IA
01
—
33226
WELLMARK
IA
01
—
DA0044
RR MEDICARE
IA
Enumeration date
05/08/2006
Last updated
07/07/2009
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