Basic Information
| Provider Information | |||||||||
| NPI: | 1447778170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNITYPOINT CLINIC PEDIATRICS FORT DODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 KENYON RD | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155746565 | ||||||||
| FaxNumber: | 5155746504 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 KENYON RD STE D | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155746855 | ||||||||
| FaxNumber: | 5155737274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GLASGO | ||||||||
| AuthorizedOfficialFirstName: | LEAH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5155733101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRINITY REGIONAL MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.