MEDICARE: DELAWARE COUNTY MEMORIAL 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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	421158372	OTHER	UNITED HEALTHCARE
2	52076B001	OTHER	TRICARE
3	52057A001	OTHER	TRICARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	52076A001	OTHER	TRICARE
8	421158372	OTHER	MIDLAND CHOICE
9	27553	OTHER	BLUE SHIELD STRAWBERRY PT
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	52057B001	OTHER	TRICARE
12	55409	OTHER	BLUE SHIELD MANCHESTER

General Provider Information

NPI Number	:	1811039886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAWARE COUNTY MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	PO BOX 359
Second Line	:	709 W MAIN ST
City	:	MANCHESTER
State	:	IA
Zip	:	52057-0359
Country	:	US
Telephone Number	:	563-927-7777
Fax Number	:	563-927-7518

Provider Business Practice Location Address
First Line	:	111 E MISSION ST
Second Line	:
City	:	STRAWBERRY POINT
State	:	IA
Zip	:	52076
Country	:	US
Telephone Number	:	563-933-7720
Fax Number	:	563-933-6277

Authorized Official
Title or Position	:	CEO
Name	:	LON BUTIKOFER
Credential	:
Telephone Number	:	563-927-7308

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	04/07/2015

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Directions to “DELAWARE COUNTY MEMORIAL HOSPITAL ” Practice Location

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