Basic Information
| Provider Information | |||||||||
| NPI: | 1649334574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEGENT HEALTH MERCY HOSPITAL CORNING, IOWA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHI HEALTH MERCY CORNING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 ROSARY DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | IA | ||||||||
| PostalCode: | 508411683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413225245 | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 ROSARY DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | IA | ||||||||
| PostalCode: | 508411683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413225245 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | JANKUSKI | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4023434409 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHI NEBRASKA | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 41469 | 01 | IA | MEDICARE PTAN | OTHER | 21536 | 01 | IA | MEDICARE PTAN | OTHER | 41473 | 01 | IA | MEDICARE PTAN | OTHER |