Basic Information
Provider Information | |||||||||
NPI: | 1124043153 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAVERLY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WAVERLY MUNICIPAL HOSPITAL | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 07/12/2006 | ||||||||
LastUpdateDate: | 03/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENNETT | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3193524120 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WAVERLY HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 090098H | IA | N |   | Hospitals | General Acute Care Hospital | Critical Access | 275N00000X | 090098H | IA | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 66094 | 01 | IA | BCBS SWING | OTHER |