Basic Information
| Provider Information | |||||||||
| NPI: | 1942365580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHENANDOAH MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHENANDOAH MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PERSHING AVE | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516012355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122461230 | ||||||||
| FaxNumber: | 7122467357 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PERSHING AVE | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516012355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122461230 | ||||||||
| FaxNumber: | 7122467357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGOUGH | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7122461230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 730065H | IA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 0600924 | 05 | IA | MEDICAID |