Basic Information
| Provider Information | |||||||||
| NPI: | 1639243116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALO ALTO COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY PRATICE CLINIC -EMMETSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 1ST ST | ||||||||
| Address2: | |||||||||
| City: | EMMETSBURG | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505362516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128525500 | ||||||||
| FaxNumber: | 7128525409 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 1ST ST | ||||||||
| Address2: | |||||||||
| City: | EMMETSBURG | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505362516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128525555 | ||||||||
| FaxNumber: | 7128525560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EINSWEILER | ||||||||
| AuthorizedOfficialFirstName: | DESIREE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7128525401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 63482 | 01 | IA | WELLMARK | OTHER | 0634857 | 05 | IA | MEDICAID |