Provider Demographics
NPI:1558880336
Name:MARY GREELEY MEDICAL CENTER
Entity Type:Organization
Organization Name:MARY GREELEY MEDICAL CENTER
Other - Org Name:NURSE PRACTIONER MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-239-2103
Mailing Address - Street 1:1111 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5745
Mailing Address - Country:US
Mailing Address - Phone:515-239-2011
Mailing Address - Fax:515-239-2060
Practice Address - Street 1:1111 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5745
Practice Address - Country:US
Practice Address - Phone:515-239-2011
Practice Address - Fax:515-239-2060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1600304Medicaid