Basic Information
Provider Information | |||||||||
NPI: | 1386836559 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BURGESS HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BURGESS FAMILY CLINIC - DECATUR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 DIAMOND ST | ||||||||
Address2: |   | ||||||||
City: | ONAWA | ||||||||
State: | IA | ||||||||
PostalCode: | 510401548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7124232311 | ||||||||
FaxNumber: | 7124239199 | ||||||||
Practice Location | |||||||||
Address1: | 823 S BROADWAY ST STE 120 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | NE | ||||||||
PostalCode: | 680202000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023495592 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2007 | ||||||||
LastUpdateDate: | 01/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 332BC3200X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 0119958 | 05 | IA |   | MEDICAID |