Provider Demographics
NPI:1780684548
Name:SUMNER COMMUNITY CLUB
Entity Type:Organization
Organization Name:SUMNER COMMUNITY CLUB
Other - Org Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:EVERDING
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:563-578-3275
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:IA
Mailing Address - Zip Code:50674-0148
Mailing Address - Country:US
Mailing Address - Phone:563-578-3275
Mailing Address - Fax:563-578-3279
Practice Address - Street 1:909 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IA
Practice Address - Zip Code:50674-1203
Practice Address - Country:US
Practice Address - Phone:563-578-3275
Practice Address - Fax:563-578-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 207P00000X, 207Q00000X, 363L00000X, 367500000X
IA090086H282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA5067404OtherJOHN DEERE
IA0601385OtherTITLE XIX
IA60138OtherBLUE CROSS (ACUTE)
IA6230725OtherAETNA
IAA5067404OtherJOHN DEERE
IA161320Medicare Oscar/Certification