Basic Information
| Provider Information | |||||||||
| NPI: | 1841220597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTGOMERY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MONTGOMERY COUNTY MEMORIAL HOSPITAL DME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 111 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RED OAK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515662238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126235466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POHREN | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7126237000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTGOMERY COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 0055541 | 05 | IA | MEDICAID |