Healthcare Provider Details

I. General information

NPI: 1730359878
Provider Name (Legal Business Name): CRAWFORD COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 MAIN STREET
MANILLA IA
51454-0000
US

IV. Provider business mailing address

2016 1ST AVE S
DENISON IA
51442-2210
US

V. Phone/Fax

Practice location:
  • Phone: 712-654-2400
  • Fax:
Mailing address:
  • Phone: 712-263-3388
  • Fax: 712-263-1777

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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0154542
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier51356
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK

VIII. Authorized Official

Name: MR. MARK H. RINEHARDT
Title or Position: ADMINISTRATOR/CEO
Credential:
Phone: 712-263-1620