Provider Demographics
NPI:1043375132
Name:MARENGO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MARENGO MEMORIAL HOSPITAL
Other - Org Name:MARENGO FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOETTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-642-5543
Mailing Address - Street 1:300 W MAY ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1261
Mailing Address - Country:US
Mailing Address - Phone:319-642-8160
Mailing Address - Fax:319-642-8069
Practice Address - Street 1:300 W MAY ST STE A
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1261
Practice Address - Country:US
Practice Address - Phone:319-741-6789
Practice Address - Fax:319-741-6791
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARENGO MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-27
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02712207Q00000X
IA38260207R00000X
IA00701213E00000X
261QR1300X
IA104766363L00000X
IA109633363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA30218OtherGROUP BCBS
IA0745489Medicaid
IA0761312Medicaid
IA2083113Medicaid
IA0761296Medicaid
IA2083113Medicaid
IA0745489Medicaid
IA0761296Medicaid
IA168563Medicare Oscar/Certification
IA30218OtherGROUP BCBS
IA30321OtherBCBS MCCUNE, DO