Provider Demographics
NPI:1306029053
Name:ELLSWORTH MUNICIPAL HOSPITAL
Entity type:Organization
Organization Name:ELLSWORTH MUNICIPAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-648-4631
Mailing Address - Street 1:324 EAST MAPLE STREET
Mailing Address - Street 2:PO BOX 487
Mailing Address - City:HUBBARD
Mailing Address - State:IA
Mailing Address - Zip Code:50122-0487
Mailing Address - Country:US
Mailing Address - Phone:641-648-3202
Mailing Address - Fax:641-648-3203
Practice Address - Street 1:324 EAST MAPLE STREET
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:IA
Practice Address - Zip Code:50122-0487
Practice Address - Country:US
Practice Address - Phone:641-648-3202
Practice Address - Fax:641-648-3203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18633261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15576OtherMEDICARE
IA2129163Medicaid
IAI15574OtherMEDICARE GROUP