Basic Information
| Provider Information | |||||||||
| NPI: | 1932140969 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COVENANT MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MERCYONE WATERLOO MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 WEST NINTH STREET | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192728000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3421 WEST NINTH STREET | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192728000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUBER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3192727600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COVENANT MEDICAL CENTER INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 070137H | IA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 0600676 | 05 | IA | MEDICAID |