Basic Information
| Provider Information | |||||||||
| NPI: | 1811960867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY COUNTY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 498 | ||||||||
| Address2: | |||||||||
| City: | RED OAK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515660498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126237000 | ||||||||
| FaxNumber: | 7126237224 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | RED OAK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515661305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126237000 | ||||||||
| FaxNumber: | 7126237224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 04/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | POHREN | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7126237000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTGOMERY COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 26870 | 05 | IA | MEDICAID |