Provider Demographics
NPI:1790758092
Name:MONTGOMERY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY MEMORIAL HOSPITAL
Other - Org Name:VILLISCA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONNEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:BADERTSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-623-7156
Mailing Address - Street 1:301 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:VILLISCA
Mailing Address - State:IA
Mailing Address - Zip Code:50864-1146
Mailing Address - Country:US
Mailing Address - Phone:712-826-4422
Mailing Address - Fax:712-826-2052
Practice Address - Street 1:301 E 4TH ST
Practice Address - Street 2:
Practice Address - City:VILLISCA
Practice Address - State:IA
Practice Address - Zip Code:50864-1146
Practice Address - Country:US
Practice Address - Phone:712-826-4422
Practice Address - Fax:712-826-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA690075H363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA=========OtherHOSPITAL TAX ID