NPIMap

Organization Active NPI

Marengo Memorial Hospital

Doing business as Marengo Family Medical Clinic

  • Rural Health Clinic/Center
  • Marengo, IA
National Provider Identifier
1043375132
Registry record updated Jan 21, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MARENGO MEMORIAL HOSPITAL
Doing business as
Marengo Family Medical Clinic
Practice address
300 W May St Ste a
Marengo, IA 52301-1261
Phone
(319) 741-6789
Fax
(319) 741-6791
NPI assigned
Dec 27, 2006
Last updated
Jan 21, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
MARENGO MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 21, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Barry G Goettsch
Title
Ceo
Phone
(319) 642-5543

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Nurse Practitioner 363L00000X 104766 IA
Pediatric Nurse Practitioner 363LP0200X 109633 IA
Family Medicine Physician 207Q00000X 02712 IA
Internal Medicine Physician 207R00000X 38260 IA
Podiatrist 213E00000X 00701 IA

Addresses

Primary practice location

300 W May St Ste a
Marengo, IA 52301-1261

Mailing address

300 W May St
Marengo, IA 52301-1261
Phone (319) 642-8160

Other identifiers 5

IdentifierTypeStateIssuer
2083113MedicaidIA
0761296MedicaidIA
30218OtherIAGROUP BCBS
0745489MedicaidIA
0761312MedicaidIA

Other names 1

  • Marengo Family Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040318000643 IA Part B Supplier - Clinic/Group Practice 0749199446 Receives reassigned benefits from 74 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Amana, IA; Belle Plaine, IA; Marengo, IA; North English, IA; Vinton, IA; Wellman, IA; Williamsburg, IA
O20140721001940 IA Part A Provider - Rural Health Clinic 0749199446 Practice locations: Marengo, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043375132. Details of each certification follow.

Rural health clinic certification: CCN 168563

Legal name
MARENGO MEMORIAL HOSPITAL
Doing business as
MARENGO FAMILY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 5, 2015
Last certification
Feb 23, 2021
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
300 W May St
Ste a
Marengo, IA 52301-1261
Related CCNs
161317

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Ben M Bagon Jr MD

Locations

300 W May St
Marengo, IA 52301
Phone (319) 462-8011

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Barry Gene Goettsch Individual Corporate OfficerCeo May 28, 2014
W-2 Managing EmployeeCeo Jul 6, 2011
Operational/Managerial ControlCeo Jul 6, 2011
Jessica Hlubek Individual Corporate Director Mar 31, 2017
Trenton a Forrest Individual Corporate Director Jun 28, 2023
Jeff Meier Individual Corporate Director Mar 23, 2022
Emily Cahoy Individual W-2 Managing Employee Aug 8, 2022
Benjamin M Miller Individual W-2 Managing EmployeeMedical Director Aug 1, 2014
Operational/Managerial ControlMedical Director Aug 1, 2014
Mary Warwick Individual W-2 Managing Employee Mar 31, 2017
Wendy Jordan Individual Corporate Director Sep 4, 2020
W-2 Managing Employee Sep 4, 2020
St Luke's Healthcare Organization, Cedar Rapids, IA Non-profit Operational/Managerial Control Jun 20, 2012
Beau Jack Individual Corporate Director Dec 4, 2023
Tessa Wade Individual Corporate Director Mar 27, 2019
Jillissa K Chvala Individual W-2 Managing EmployeeClinic Manager Feb 23, 2022
Operational/Managerial ControlClinic Managaer Feb 23, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 19

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 19

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579564800000",
    "number": "1043375132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 W MAY ST",
            "city": "MARENGO",
            "state": "IA",
            "postal_code": "523011261",
            "telephone_number": "319-642-8160",
            "fax_number": "319-642-8069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 W MAY ST STE A",
            "city": "MARENGO",
            "state": "IA",
            "postal_code": "523011261",
            "telephone_number": "319-741-6789",
            "fax_number": "319-741-6791"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARENGO MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARENGO MEMORIAL HOSPITAL",
        "enumeration_date": "2006-12-27",
        "last_updated": "2020-01-21",
        "certification_date": "2020-01-21",
        "status": "A",
        "authorized_official_last_name": "GOETTSCH",
        "authorized_official_first_name": "BARRY",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "319-642-5543"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IA",
            "license": "104766",
            "primary": false
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "IA",
            "license": "109633",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IA",
            "license": "02712",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IA",
            "license": "38260",
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "IA",
            "license": "00701",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2083113",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0761296",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP BCBS",
            "identifier": "30218",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0745489",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0761312",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marengo Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Marengo Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marengo, IA

Sources for this page

Verify at the official NPI Registry.