Provider Demographics
NPI:1508431875
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:319-768-3622
Mailing Address - Fax:
Practice Address - Street 1:2750 MOUNT PLEASANT ST STE 104
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-2171
Practice Address - Country:US
Practice Address - Phone:319-752-7727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT RIVER MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty