1477594661 NPI number — COVENANT MEDICAL CENTER INC

Table of content: (NPI 1477594661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477594661 NPI number — COVENANT MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT MEDICAL CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MERCYONE ARLINGTON FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477594661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 W 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50702-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-272-7600
Provider Business Mailing Address Fax Number:
319-272-7597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50606-9754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-633-6965
Provider Business Practice Location Address Fax Number:
563-633-6985
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUBER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
319-272-7600

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06-34386 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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