1780755728 NPI number — BUENA VISTA REGIONAL MEDICAL CENTER

Table of content: (NPI 1780755728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780755728 NPI number — BUENA VISTA REGIONAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUENA VISTA REGIONAL MEDICAL CENTER
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:
BUENA VISTA REGIONAL MEDICAL CENTER DEPT OF EKG
Provider Other Organization Name Type Code:
5
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:
1780755728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1525 W 5TH ST
Provider Second Line Business Mailing Address:
PO BOX 309
Provider Business Mailing Address City Name:
STORM LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50588-3027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-732-4030
Provider Business Mailing Address Fax Number:
712-213-1233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1525 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STORM LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50588-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-732-4030
Provider Business Practice Location Address Fax Number:
712-213-1233
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KETCHAM
Authorized Official First Name:
KRISTA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
712-213-8603

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  166H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 166H , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 110166H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 110166H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 30564 . This is a "WELLMARK GROUP NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0078782 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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