Basic Information
| Provider Information | |||||||||
| NPI: | 1013243633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BURGESS HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BURGESS FAMILY CLINIC - SLOAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | ONAWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510401548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124232311 | ||||||||
| FaxNumber: | 7124239199 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 EVANS ST | ||||||||
| Address2: | |||||||||
| City: | SLOAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510557748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124284100 | ||||||||
| FaxNumber: | 7124284102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEHNE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7124232311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BURGESS HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363L00000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QR1300X | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0634865 | 05 | IA | MEDICAID |