Provider Demographics
NPI:1164593109
Name:BUENA VISTA REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:BUENA VISTA REGIONAL MEDICAL CENTER
Other - Org Name:ER PHYSICIAN GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KETCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-213-8603
Mailing Address - Street 1:1525 W 5TH ST
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-3027
Mailing Address - Country:US
Mailing Address - Phone:712-732-4030
Mailing Address - Fax:712-213-1233
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3027
Practice Address - Country:US
Practice Address - Phone:712-732-4030
Practice Address - Fax:712-213-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA166H207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0097956Medicaid
IA12089OtherWELLMARK GROUP NUMBER
IA=========OtherTAX ID NUMBER
IN0097956Medicaid