=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982113163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPENCER MUNICIPAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2017
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 1ST AVE E
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51301-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-264-6391
-----------------------------------------------------
Fax | 952-653-2540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6501 CITY WEST PKWY
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-653-2565
-----------------------------------------------------
Fax | 952-653-2540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRENDA TIEFENTHALER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 712-264-6391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 571
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------