Basic Information
| Provider Information | |||||||||
| NPI: | 1487740486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVIS COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAVIS COUTNY HOSPITAL PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 509 N MADISON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525371271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416642145 | ||||||||
| FaxNumber: | 6416641669 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N MADISON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525371271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416642145 | ||||||||
| FaxNumber: | 6416641669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARNING | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6416642145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17938 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0179382 | 05 | IA | MEDICAID |