Basic Information
| Provider Information | |||||||||
| NPI: | 1447470463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY GREELEY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152392112 | ||||||||
| FaxNumber: | 5152392060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152392112 | ||||||||
| FaxNumber: | 5152392060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | DIETER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5152392102 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 2850100 | IA | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 0112573 | 05 | IA | MEDICAID |