Basic Information
| Provider Information | |||||||||
| NPI: | 1275697039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLSWORTH MUNICIPAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURGERY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 S OAK ST | ||||||||
| Address2: | |||||||||
| City: | IOWA FALLS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501269506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416487000 | ||||||||
| FaxNumber: | 6416487019 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 S OAK ST | ||||||||
| Address2: | |||||||||
| City: | IOWA FALLS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501269506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416487000 | ||||||||
| FaxNumber: | 6416487019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEDERHOFF | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6416487101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLSWORTH MUNICIPAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 420156H | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.