=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174754436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2009
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 KENYON RD
-----------------------------------------------------
City | FORT DODGE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50501-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-573-3101
-----------------------------------------------------
Fax | 515-573-8710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2818
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50704-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-233-3044
-----------------------------------------------------
Fax | 319-233-0722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MICHAEL J DEWERFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-574-6603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------