Basic Information
| Provider Information | |||||||||
| NPI: | 1366442295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMNER COMMUNITY CLUB DBA COMMUNITY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY MEMORIAL HOSPITAL (SWING BED) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 148 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506740148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635783275 | ||||||||
| FaxNumber: | 5635783279 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506741203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635783275 | ||||||||
| FaxNumber: | 5635783279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVERDING | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATOR/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5635783275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMNER COMMUNITY CLUB | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 0601385 | 01 | TITLE XIX | OTHER | A5067404 | 01 | JOHN DEERE | OTHER | 6230725 | 01 | AETNA | OTHER | 66138 | 01 | BLUE CROSS (SWING BED) | OTHER |