Provider Demographics
NPI:1013058924
Name:STEWART MEMORIAL COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:STEWART MEMORIAL COMMUNITY HOSPITAL
Other - Org Name:MCCRARY-ROST CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENKENIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-464-4200
Mailing Address - Street 1:1301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-1585
Mailing Address - Country:US
Mailing Address - Phone:712-464-3171
Mailing Address - Fax:712-464-3269
Practice Address - Street 1:1301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1585
Practice Address - Country:US
Practice Address - Phone:712-464-3171
Practice Address - Fax:712-464-3269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEWART MEMORIAL COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X, 208600000X, 363A00000X, 363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0007880Medicaid
IA0007880Medicaid