Basic Information
| Provider Information | |||||||||
| NPI: | 1033125463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAVERLY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAVERLY HEALTH CENTER ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | 3193523992 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | 3193523992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3193524120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAVERLY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 21299 | 01 | IA | BLUE CROSS OF IOWA | OTHER | 0735613 | 05 | IA | MEDICAID |