Basic Information
| Provider Information | |||||||||
| NPI: | 1033282975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAVERLY HEALTH CENTER | ||||||||
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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: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3193524120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAVERLY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0070573 | 05 | IA | MEDICAID | 03296 | 01 | IA | BCBS WHC ER PHYSICIAN SVC | OTHER |