Provider Demographics
NPI:1558496620
Name:MONTGOMERY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY MEMORIAL HOSPITAL
Other - Org Name:WAIVER
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONNEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BADERTSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-623-7156
Mailing Address - Street 1:PO BOX 498
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-0498
Mailing Address - Country:US
Mailing Address - Phone:712-623-7156
Mailing Address - Fax:712-623-7224
Practice Address - Street 1:2301 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-0498
Practice Address - Country:US
Practice Address - Phone:712-623-7156
Practice Address - Fax:712-623-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA690075H133V00000X, 332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Not Answered332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0164715Medicaid