Provider Demographics
NPI:1164433884
Name:SOUTHEAST IOWA REGIONAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHEAST IOWA REGIONAL MEDICAL CENTER, INC.
Other - Org Name:GREAT RIVER MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-3268
Mailing Address - Street 1:1221 S GEAR AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1679
Mailing Address - Country:US
Mailing Address - Phone:319-768-3626
Mailing Address - Fax:319-768-3633
Practice Address - Street 1:1221 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1679
Practice Address - Country:US
Practice Address - Phone:319-768-3626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0121129Medicaid
CH2540OtherTRAVELERS MEDICARE
35449OtherBLUE CROSS
IA0121129Medicaid