Basic Information
Provider Information | |||||||||
NPI: | 1598959371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAVERLY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
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: | 09/05/2007 | ||||||||
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 | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 208600000X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 225100000X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 363A00000X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363LX0001X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 225X00000X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 207V00000X |   | IA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207Q00000X |   | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0700319 | 05 | IA |   | MEDICAID | 70127 | 01 | IA | WELLMARK | OTHER |