Healthcare Provider Details

I. General information

NPI: 1043375132
Provider Name (Legal Business Name): MARENGO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MAY ST STE A
MARENGO IA
52301-1261
US

IV. Provider business mailing address

300 W MAY ST
MARENGO IA
52301-1261
US

V. Phone/Fax

Practice location:
  • Phone: 319-741-6789
  • Fax: 319-741-6791
Mailing address:
  • Phone: 319-642-8160
  • Fax: 319-642-8069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02712
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38260
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00701
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number104766
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number109633
License Number StateIA
# 6
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARRY G GOETTSCH
Title or Position: CEO
Credential:
Phone: 319-642-5543