Basic Information
Provider Information | |||||||||
NPI: | 1659357457 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARY GREELEY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 DUFF AVE | ||||||||
Address2: |   | ||||||||
City: | AMES | ||||||||
State: | IA | ||||||||
PostalCode: | 500105745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152392011 | ||||||||
FaxNumber: | 5152392060 | ||||||||
Practice Location | |||||||||
Address1: | 701 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | IOWA FALLS | ||||||||
State: | IA | ||||||||
PostalCode: | 501262100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6416485241 | ||||||||
FaxNumber: | 6416483628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 12/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIETER | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 5152392011 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 0600304 | 05 | IA |   | MEDICAID |