Basic Information
| Provider Information | |||||||||
| NPI: | 1356359061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLSWORTH MUNICIPAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACKLEY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 10TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | ACKLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506011456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418472625 | ||||||||
| FaxNumber: | 6418472509 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | ACKLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506011701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418472625 | ||||||||
| FaxNumber: | 6418472509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEDERHOFF | ||||||||
| AuthorizedOfficialFirstName: | DARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLUSTER MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6418472625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLSWORTH MUNICIPAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0442764 | 05 | IA | MEDICAID | I12852 | 01 | IA | MEDICARE-PTAN | OTHER |