Basic Information
| Provider Information | |||||||||
| NPI: | 1790758092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTGOMERY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | VILLISCA MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | VILLISCA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 508641146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128264422 | ||||||||
| FaxNumber: | 7128262052 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | VILLISCA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 508641146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128264422 | ||||||||
| FaxNumber: | 7128262052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BADERTSCHER | ||||||||
| AuthorizedOfficialFirstName: | RONNEL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7126237156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 690075H | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.