NPIMap

Organization Active NPI

Wayne County Hospital

Doing business as South Central Iowa Medical Clinic

  • Rural Health Clinic/Center
  • Corydon, IA
National Provider Identifier
1104125822
Registry record updated Nov 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
WAYNE COUNTY HOSPITAL
Doing business as
South Central Iowa Medical Clinic
Practice address
417 S East St
Suite 100
Corydon, IA 50060-1860
Phone
(641) 872-2063
Fax
(641) 872-2070
NPI assigned
Mar 21, 2011
Last updated
Nov 21, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 21, 2017

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

Authorized official

Name
Daren L Relph
Title
Chief Executive Officer
Phone
(641) 872-2260

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Advanced Practice MidwifeGroup: 193200000X MULTI-SPECIALTY GROUP 367A00000X

Addresses

Primary practice location

417 S East St
Suite 100
Corydon, IA 50060-1860

Mailing address

PO Box 305
Corydon, IA 50060-0305
Phone (641) 872-5351

Other names 1

  • South Central Iowa 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
O20040212000233 IA Part B Supplier - Clinic/Group Practice 4082508734 Receives reassigned benefits from 59 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Corydon, IA; Humeston, IA; Seymour, ID
O20120328000047 IA Part A Provider - Rural Health Clinic 4082508734 Practice locations: Corydon, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104125822. Details of each certification follow.

Rural health clinic certification: CCN 168547

Legal name
WAYNE COUNTY HOSPITAL
Doing business as
SOUTH CENTRAL IOWA MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 8, 2012
Last certification
Jun 21, 2018
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
417 S East St
Ste 100
Corydon, IA 50060-1860
Related CCNs
161358

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 6

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

National Provider Directory

National Provider Directory

Locations

417 S East St
Ste 100
Corydon, IA 50060
Phone (515) 872-2063

Interoperability endpoints

  • FHIR API: https://fhir-usa.unify.chbase.com/org/wayneco-3602361a

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Denise a Hook Individual Corporate OfficerChief Financial Officer Aug 27, 2010
Operational/Managerial ControlCfo Jan 1, 2011
Rhonda Ewing Individual Corporate Director Jan 1, 2015
Darrell Cook Individual Corporate DirectorBoard Member Jan 1, 2010
Daren L Relph Individual Corporate OfficerChief Executive Officer Jun 1, 2010 100%
Operational/Managerial ControlCeo Jun 1, 2010 100%
Donna Donald Individual Corporate Director Jan 1, 2008
Wayne County Hospital Organization, Corydon, IA 5% Or Greater Direct Ownership Interest Apr 1, 2011 100%
Cynthia Shelley Individual Corporate Director Jan 1, 2021
Dewayne Watters Individual Corporate Director Jun 1, 2021
Jill Tueth Individual Corporate DirectorBoard Member Jan 1, 2010
Bridget Davis Individual Corporate Director Aug 1, 2021

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Lineville Medical ClinicLineville, IA, CCN 163435 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 13, 2010
Seymour Medical ClinicSeymour, IA, CCN 168541 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2010
Humeston Family Medical ClinicHumeston, IA, CCN 168548 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2011

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1300665600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1511222400000",
    "number": "1104125822",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 305",
            "city": "CORYDON",
            "state": "IA",
            "postal_code": "500600305",
            "telephone_number": "641-872-5351",
            "fax_number": "641-872-3116"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "417 S EAST ST",
            "address_2": "SUITE 100",
            "city": "CORYDON",
            "state": "IA",
            "postal_code": "500601860",
            "telephone_number": "641-872-2063",
            "fax_number": "641-872-2070"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAYNE COUNTY HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-21",
        "last_updated": "2017-11-21",
        "status": "A",
        "authorized_official_last_name": "RELPH",
        "authorized_official_first_name": "DAREN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "641-872-2260"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "367A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Advanced Practice Midwife",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Central Iowa Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Corydon, IA

Sources for this page

Verify at the official NPI Registry.