Provider Demographics
NPI:1548681216
Name:MARENGO MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MARENGO MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOETTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:319-642-5543
Mailing Address - Street 1:300 W MAY ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1261
Mailing Address - Country:US
Mailing Address - Phone:319-642-8160
Mailing Address - Fax:319-642-8069
Practice Address - Street 1:498 N HIGHLAND ST.
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:IA
Practice Address - Zip Code:52361-9695
Practice Address - Country:US
Practice Address - Phone:319-668-6789
Practice Address - Fax:319-668-6791
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARENGO MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-26
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA168564Medicare Oscar/Certification