Basic Information
Provider Information | |||||||||
NPI: | 1578682522 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOLDEN VALLEY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 N 2ND ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 647351192 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608907103 | ||||||||
FaxNumber: | 6608858496 | ||||||||
Practice Location | |||||||||
Address1: | 1600 N 2ND ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MO | ||||||||
PostalCode: | 647351192 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608907103 | ||||||||
FaxNumber: | 6608858496 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2007 | ||||||||
LastUpdateDate: | 06/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WERTZ | ||||||||
AuthorizedOfficialFirstName: | RANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6608907103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 257-35 | MO | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 800565608 | 05 | MO |   | MEDICAID |