1558496620 NPI number — MONTGOMERY COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1558496620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558496620 NPI number — MONTGOMERY COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTGOMERY COUNTY MEMORIAL HOSPITAL
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:
Provider Other Organization Name Type Code:
6
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:
1558496620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED OAK
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51566-0498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-623-7156
Provider Business Mailing Address Fax Number:
712-623-7224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 EASTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED OAK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51566-0498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-623-7156
Provider Business Practice Location Address Fax Number:
712-623-7224
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BADERTSCHER
Authorized Official First Name:
RONNEL
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
712-623-7156

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  690075H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332U00000X , with the licence number: 690075H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 0164715 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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