Basic Information
| Provider Information | |||||||||
| NPI: | 1942251269 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JENNIE EDMUNDSON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JE PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2797 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681032797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544230 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 E PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123966000 | ||||||||
| FaxNumber: | 7123966288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAUMERT | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7123966064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 088716 | 05 | IA | MEDICAID | 10025220600 | 05 | NE | MEDICAID | 10025873100 | 05 | NE | MEDICAID | 10025857700 | 05 | NE | MEDICAID | 08871 | 01 | IA | WELLMARK | OTHER | CV0019 | 01 | IA | RAILROAD | OTHER |