Provider Demographics
NPI:1508101221
Name:PELLA REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:PELLA REGIONAL HEALTH CENTER
Other - Org Name:OTTUMWA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:KROESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-628-6604
Mailing Address - Street 1:920 N QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3866
Mailing Address - Country:US
Mailing Address - Phone:641-455-5200
Mailing Address - Fax:641-455-5150
Practice Address - Street 1:920 N QUINCY AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3866
Practice Address - Country:US
Practice Address - Phone:641-455-5200
Practice Address - Fax:641-455-5150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PELLA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA630165H261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA168562Medicare PIN