Provider Demographics
NPI:1780755728
Name:BUENA VISTA REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:BUENA VISTA REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KETCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-213-8603
Mailing Address - Street 1:1525 W 5TH ST
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-3027
Mailing Address - Country:US
Mailing Address - Phone:712-732-4030
Mailing Address - Fax:712-213-1233
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3027
Practice Address - Country:US
Practice Address - Phone:712-732-4030
Practice Address - Fax:712-213-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA166H207RC0000X
207RE0101X, 207X00000X, 208800000X, 208M00000X, 213E00000X, 363A00000X, 363L00000X, 367500000X
IA110166H208600000X, 363LP0808X
IN166H2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0078782Medicaid
IA30564OtherWELLMARK GROUP NUMBER
IA30564OtherWELLMARK GROUP NUMBER
IA0078782Medicaid