=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174568794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OTTUMWA REGIONAL HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 PENNSYLVANIA AVE CENTRAL CLINIC BILLING
-----------------------------------------------------
City | OTTUMWA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52501-6427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-684-3053
-----------------------------------------------------
Fax | 641-683-2855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 PENNSYLVANIA AVE CENTRAL CLINIC BILLING
-----------------------------------------------------
City | OTTUMWA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52501-6427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-684-3053
-----------------------------------------------------
Fax | 641-683-2855
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERIM PRESIDENT CEO
-----------------------------------------------------
Name | MR. THOMAS R. SIEMERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 641-684-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------