Provider Demographics
NPI:1972771384
Name:JEFFERSON COUNTY HOSPITAL
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HOSPITAL
Other - Org Name:JCH PROFESSIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:PEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-469-4304
Mailing Address - Street 1:2000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-9572
Mailing Address - Country:US
Mailing Address - Phone:641-469-4204
Mailing Address - Fax:641-469-4208
Practice Address - Street 1:2000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-9572
Practice Address - Country:US
Practice Address - Phone:641-469-4204
Practice Address - Fax:641-469-4208
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37410207RG0100X
IA22423208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0468850Medicaid
IA33819OtherWELLMARK BC/BS OF IA
IAI10350Medicare PIN