Basic Information
| Provider Information | |||||||||
| NPI: | 1053369405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PELLA REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PELLA MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416283832 | ||||||||
| FaxNumber: | 6416288894 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416283832 | ||||||||
| FaxNumber: | 6416288894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | KROESE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6416286604 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 630165H | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 630165H | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM1300X | 630165H | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 0147223 | 05 | IA | MEDICAID | 16D0383077 | 01 | IA | CLIA NUMBER | OTHER | CC5750 | 01 | IA | RAILROAD MEDICARE | OTHER |