Basic Information
| Provider Information | |||||||||
| NPI: | 1780684548 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMNER COMMUNITY CLUB | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 148 | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506740148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635783275 | ||||||||
| FaxNumber: | 5635783279 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SUMNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506741203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635783275 | ||||||||
| FaxNumber: | 5635783279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVERDING | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5635783275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 282NC0060X | 090086H | IA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | A5067404 | 01 | IA | JOHN DEERE | OTHER | 0601385 | 01 | IA | TITLE XIX | OTHER | 60138 | 01 | IA | BLUE CROSS (ACUTE) | OTHER | 6230725 | 01 | IA | AETNA | OTHER |