Healthcare Provider Details

I. General information

NPI: 1205300498
Provider Name (Legal Business Name): MOSAIC MEDICAL CENTER - MARYVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 DODGE ST
BEDFORD IA
50833-1413
US

IV. Provider business mailing address

408 DODGE ST
BEDFORD IA
50833-1413
US

V. Phone/Fax

Practice location:
  • Phone: 712-523-2738
  • Fax: 712-523-3256
Mailing address:
  • Phone: 712-523-2738
  • Fax: 712-523-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DWIGHT R CARVELL
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 816-273-0473