Basic Information
Provider Information
NPI: 1750367553
EntityType: 2
ReplacementNPI:  
OrganizationName: MARY GREELEY MEDICAL CENTER
LastName:  
FirstName:  
MiddleName:  
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NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 1111 DUFF AVE
Address2:  
City: AMES
State: IA
PostalCode: 500105745
CountryCode: US
TelephoneNumber: 5152392011
FaxNumber: 5152392060
Practice Location
Address1: 2322 E 13TH ST
Address2:  
City: AMES
State: IA
PostalCode: 500105669
CountryCode: US
TelephoneNumber: 5152396800
FaxNumber: 5152338151
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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QE0700X  Y Ambulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment

ID Information
IDTypeStateIssuerDescription
060030405IA MEDICAID


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