| Contacts | Primary Contact | Update | PC Change Request | Edmonds, Keri E
Clinical Informatics and Quality Programs Manager
Eastern Iowa Health Center
3197307388 | Davis, Michele Renee
Director of Quality & Risk Managment
Eastern Iowa Health Center
3197307300-7388 | 2/13/2025 9:40 AM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2024 4:23:09 PM | 2/10/2025 10:55:28 AM | 2/10/2025 10:55 AM |
| Details | Last Recertification Date | Update | Recertification | 2/6/2023 12:12:38 PM | 1/31/2024 4:23:09 PM | 1/31/2024 4:23 PM |
| Addresses | Main Address | Update | Change Request |
1225 3rd Ave SE
Cedar Rapids, IA 52403 |
1210 Fourth Avenue SE
Cedar Rapids, IA 52403 | 1/10/2024 1:09 PM |
| Details | Entity Subname | Update | Change Request | Eastern Iowa Dental Center | Eastern Iowa Health Center - Dental | 1/10/2024 1:09 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2022 4:36:58 PM | 2/6/2023 12:12:38 PM | 2/6/2023 12:12 PM |
| Details | Last Recertification Date | Update | Recertification | 2/23/2021 5:51:32 PM | 2/4/2022 4:36:58 PM | 2/4/2022 4:36 PM |
| Contacts | Primary Contact | Update | Change Request | Langdon, Erin
Chief Development Officer
Eastern Iowa Health Center
3197307343 | Edmonds, Keri E
Clinical Informatics and Quality Programs Manager
Eastern Iowa Health Center
3197307388 | 6/7/2021 5:53 PM |
| Details | Last Recertification Date | Update | Recertification | 2/12/2020 3:33:24 PM | 2/23/2021 5:51:32 PM | 2/23/2021 5:51 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1437600053 ( ) | | 10/28/2020 1:40 PM |
| Addresses | Billing Address | Update | Recertification | Eastern Iowa Health Center
Administrative Office
1030 5th Avenue SE, STE 2400
Cedar Rapids, IA 52403-2478 | Eastern Iowa Health Center
1030 5th Avenue SE
Suite 2400
Cedar Rapids, IA 52403-2478 | 2/12/2020 3:33 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2019 11:31:08 AM | 2/12/2020 3:33:24 PM | 2/12/2020 3:33 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2018 3:42:30 PM | 1/30/2019 11:31:08 AM | 1/30/2019 11:31 AM |
| Contacts | Primary Contact | Update | Recertification | Lock, James
President & CEO
Eastern Iowa Health Center
3197307300 | Langdon, Erin
Chief Development Officer
Eastern Iowa Health Center
3197307343 | 2/7/2018 3:42 PM |
| Details | Last Recertification Date | Update | Recertification | | 2/7/2018 3:42:30 PM | 2/7/2018 3:42 PM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/7/2018 3:42 PM |
| Contacts | Authorizing Official | Update | | Lock, James
President & CEO
3197307300 | Lock, James
President & CEO
Eastern Iowa Health Center
3197307300 | 2/7/2018 2:57 PM |
| Contacts | Primary Contact | Update | | Lock, James
President & CEO
3197307300 | Lock, James
President & CEO
Eastern Iowa Health Center
3197307300 | 2/7/2018 2:57 PM |
| Contacts | Signed By | Update | | Lock, James
President & CEO
3197307300 | Lock, James
President & CEO
Eastern Iowa Health Center
3197307300 | 2/7/2018 2:57 PM |
| Contacts | Authorizing Official | Insert | | | Lock, James
President & CEO
3197307300 | 7/13/2017 5:06 PM |
| Contacts | Primary Contact | Insert | | | Lock, James
President & CEO
3197307300 | 7/13/2017 5:06 PM |
| Contacts | Signed By | Insert | | | Lock, James
President & CEO
3197307300 | 7/13/2017 5:06 PM |
| Addresses | Main Address | Insert | | |
1225 3rd Ave SE
Cedar Rapids, IA 52403 | 5/15/2017 5:57 PM |
| Addresses | Billing Address | Insert | | | Eastern Iowa Health Center
Administrative Office
1030 5th Avenue SE, STE 2400
Cedar Rapids, IA 52403-2478 | 4/24/2017 10:29 AM |
| Dates | Participating Approval Date | Update | | | 4/24/2017 12:00:00 AM | 4/24/2017 10:28 AM |
| Details | State | Update | | Pending | Active | 4/24/2017 10:28 AM |
| Dates | Start Date | Update | | | 7/1/2017 12:00:00 AM | 4/24/2017 10:28 AM |
| Details | 340B ID | Update | | ONLINE_REG_75750 | CH071857B | 4/3/2017 1:44 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_75750 | 4/3/2017 11:38 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1437600053 | 4/3/2017 11:38 AM |
| Details | Last Recertification Date | Insert | | | | 4/3/2017 11:38 AM |
| Details | Grant Number | Insert | | | H80CS08226 | 4/3/2017 11:38 AM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/3/2017 11:38 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/3/2017 11:38 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/3/2017 11:38 AM |
| Details | Medicare Provider Number | Insert | | | | 4/3/2017 11:38 AM |
| Details | Entity Name | Insert | | | EASTERN IOWA HEALTH CENTER | 4/3/2017 11:38 AM |
| Details | Program Code | Insert | | | CH | 4/3/2017 11:38 AM |
| Details | Entity Subname | Insert | | | Eastern Iowa Dental Center | 4/3/2017 11:38 AM |
| Dates | Participating Approval Date | Insert | | | | 4/3/2017 11:38 AM |
| Details | State | Insert | | | Pending | 4/3/2017 11:38 AM |
| Dates | Registration Date | Insert | | | 4/3/2017 12:00:00 AM | 4/3/2017 11:38 AM |
| Dates | Signed By Date | Insert | | | 4/3/2017 12:00:00 AM | 4/3/2017 11:38 AM |
| Dates | Start Date | Insert | | | | 4/3/2017 11:38 AM |
| Terminations | Termination Comments | Insert | | | | 4/3/2017 11:38 AM |
| Terminations | Termination Date | Insert | | | | 4/3/2017 11:38 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/3/2017 11:38 AM |
| Terminations | Termination Reason | Insert | | | | 4/3/2017 11:38 AM |