Provider Demographics
NPI:1275697039
Name:ELLSWORTH MUNICIPAL HOSPITAL
Entity Type:Organization
Organization Name:ELLSWORTH MUNICIPAL HOSPITAL
Other - Org Name:SURGERY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:S
Authorized Official - Last Name:NEDERHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-648-7101
Mailing Address - Street 1:920 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:IOWA FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50126-9506
Mailing Address - Country:US
Mailing Address - Phone:641-648-7000
Mailing Address - Fax:641-648-7019
Practice Address - Street 1:920 S OAK ST
Practice Address - Street 2:
Practice Address - City:IOWA FALLS
Practice Address - State:IA
Practice Address - Zip Code:50126-9506
Practice Address - Country:US
Practice Address - Phone:641-648-7000
Practice Address - Fax:641-648-7019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLSWORTH MUNICIPAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA420156H208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAC96929Medicare UPIN
IAI3501Medicare PIN