Provider Demographics
NPI:1952466419
Name:SHENANDOAH MEDICAL CENTER
Entity Type:Organization
Organization Name:SHENANDOAH MEDICAL CENTER
Other - Org Name:SHENANDOAH MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-246-1230
Mailing Address - Street 1:300 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2355
Mailing Address - Country:US
Mailing Address - Phone:712-246-1230
Mailing Address - Fax:712-246-7357
Practice Address - Street 1:300 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2355
Practice Address - Country:US
Practice Address - Phone:712-246-1230
Practice Address - Fax:712-246-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA730065H207Q00000X, 207R00000X, 207V00000X, 208600000X
IA27220207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0423467Medicaid
IAI7493Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER