MEDICARE: SPENCER MUNICIPAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	37H	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760479554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPENCER MUNICIPAL HOSPITAL

Provider Business Mailing Address
First Line	:	1200 1ST AVE E
Second Line	:
City	:	SPENCER
State	:	IA
Zip	:	51301-4330
Country	:	US
Telephone Number	:	712-264-6111
Fax Number	:	712-264-6404

Provider Business Practice Location Address
First Line	:	3150 18TH ST
Second Line	:
City	:	SPIRIT LAKE
State	:	IA
Zip	:	51360-7468
Country	:	US
Telephone Number	:	712-336-2910
Fax Number	:	712-336-4026

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	BRENDA TIEFENTHALER
Credential	:
Telephone Number	:	712-264-6111

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	10/10/2023

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