Provider Demographics
NPI:1598959371
Name:WAVERLY HEALTH CENTER
Entity Type:Organization
Organization Name:WAVERLY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-352-4120
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2929
Mailing Address - Country:US
Mailing Address - Phone:319-352-4120
Mailing Address - Fax:319-352-3992
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2929
Practice Address - Country:US
Practice Address - Phone:319-352-4120
Practice Address - Fax:319-352-3992
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAVERLY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-05
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X, 207V00000X, 208600000X, 225100000X, 225X00000X, 363A00000X, 363LX0001X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0700319Medicaid
IA70127OtherWELLMARK
IA03296Medicare PIN