Provider Demographics
NPI:1841393493
Name:SHELBY COUNTY CHRIS A MYRTUE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SHELBY COUNTY CHRIS A MYRTUE MEMORIAL HOSPITAL
Other - Org Name:MYRTUE MEDICAL CENTER - AVOCA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-755-4315
Mailing Address - Street 1:1213 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-2057
Mailing Address - Country:US
Mailing Address - Phone:712-755-5161
Mailing Address - Fax:712-755-4412
Practice Address - Street 1:510 N ELM ST
Practice Address - Street 2:
Practice Address - City:AVOCA
Practice Address - State:IA
Practice Address - Zip Code:51521-3521
Practice Address - Country:US
Practice Address - Phone:712-343-6455
Practice Address - Fax:712-343-6704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBY COUNTY CHRIS A MYRTUE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-07
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0685156Medicaid
IA168517Medicare Oscar/Certification