Basic Information
| Provider Information | |||||||||
| NPI: | 1710050661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BURGESS HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BURGESS HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | ONAWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510401548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124232311 | ||||||||
| FaxNumber: | 7124239199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | ONAWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510401548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124239265 | ||||||||
| FaxNumber: | 7124239199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEHNE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7124232311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BURGESS HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 081001 | NE | N | Agencies | Home Health | 251E00000X | NONE | IA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0671461 | 05 | IA | MEDICAID | 67146 | 01 | IA | BCBS HOMES HEALTH | OTHER | 34605 | 01 | IA | BCBS WELLMARK HIT 34605 | OTHER |