1639747108 NPI number — MARENGO MEMORIAL HOSPITAL

Table of content: (NPI 1639747108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639747108 NPI number — MARENGO MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARENGO 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:
COLONIES FAMILY MEDICAL CLINIC
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:
1639747108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 W MAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARENGO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52301-1261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-642-8160
Provider Business Mailing Address Fax Number:
319-642-8069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
728 47TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMANA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52203-8031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-225-8700
Provider Business Practice Location Address Fax Number:
319-225-8660
Provider Enumeration Date:
06/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GOETTSCH
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
319-642-8160

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)





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