Provider Demographics
NPI:1972667731
Name:ELLSWORTH MUNICIPAL HOSPITAL
Entity Type:Organization
Organization Name:ELLSWORTH MUNICIPAL HOSPITAL
Other - Org Name:MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-648-4631
Mailing Address - Street 1:110 ROCKSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50126-2431
Mailing Address - Country:US
Mailing Address - Phone:641-648-4631
Mailing Address - Fax:641-648-2850
Practice Address - Street 1:110 ROCKSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:IOWA FALLS
Practice Address - State:IA
Practice Address - Zip Code:50126-2431
Practice Address - Country:US
Practice Address - Phone:641-648-4631
Practice Address - Fax:641-648-2850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLSWORTH MUNICIPAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-19
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA420156H273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA60034OtherBLUE CROSS MH PROVIDER
IA0600346Medicaid
IA0600346Medicaid