Provider Demographics
NPI:1386623262
Name:GREAT RIVER MEDICAL CENTER
Entity type:Organization
Organization Name:GREAT RIVER MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-3260
Mailing Address - Street 1:1221 S GEAR AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1679
Mailing Address - Country:US
Mailing Address - Phone:319-768-3628
Mailing Address - Fax:
Practice Address - Street 1:1307 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1604
Practice Address - Country:US
Practice Address - Phone:319-768-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2900147H313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800409Medicaid