Healthcare Provider Details

I. General information

NPI: 1174754436
Provider Name (Legal Business Name): TRINITY REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

PO BOX 2818
WATERLOO IA
50704-2818
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax: 515-573-8710
Mailing address:
  • Phone: 319-233-3044
  • Fax: 319-233-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J DEWERFF
Title or Position: CFO
Credential:
Phone: 515-574-6603