Basic Information
| Provider Information | |||||||||
| NPI: | 1841393493 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELBY COUNTY CHRIS A MYRTUE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MYRTUE MEDICAL CENTER - AVOCA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1213 GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | HARLAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515372057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127555161 | ||||||||
| FaxNumber: | 7127554412 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | AVOCA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515213521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123436455 | ||||||||
| FaxNumber: | 7123436704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSEN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7127554315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHELBY COUNTY CHRIS A MYRTUE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0685156 | 05 | IA | MEDICAID |