NPIMap

Organization Active NPI

Marengo Memorial Hospital

Doing business as Colonies Family Medical Clinic

  • Rural Health Clinic/Center
  • Amana, IA
National Provider Identifier
1639747108
Registry record updated Jun 17, 2021
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
Colonies Family Medical Clinic
Practice address
728 47TH Ave
Amana, IA 52203-8031
Phone
(319) 225-8700
Fax
(319) 225-8660
NPI assigned
Jun 11, 2021
Last updated
Jun 17, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
MARENGO MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 17, 2021

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) 642-8160

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

728 47TH Ave
Amana, IA 52203-8031

Mailing address

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

Other names 1

  • COLONIES FAMILY MEDICAL CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211020002943 IA Part A Provider - Rural Health Clinic 0749199446 Practice locations: Amana, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639747108. Details of each certification follow.

Rural health clinic certification: CCN 168657

Legal name
MARENGO MEMORIAL HOSPITAL
Doing business as
COLONIES FAMILY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 16, 2021
Last certification
Dec 16, 2021
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
728 47TH Ave
Amana, IA 52203-8031
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).

National Provider Directory

National Provider Directory
Tax ID family
Ben M Bagon Jr MD9 organizations share this tax ID, including this one
Part of
Ben M Bagon Jr MD

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

300 W May St
Ste A
Marengo, IA 52301
Phone (319) 642-5543

Ownership & related parties

All disclosed owners & managing parties 11

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 Officer Jan 23, 2019
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
Mary Warwick Individual W-2 Managing EmployeeDirector of Administrative Services Jan 1, 2010
Wendy Jordan Individual Corporate OfficerCfo Sep 4, 2020
W-2 Managing EmployeeCfo Sep 4, 2020
Operational/Managerial ControlCfo Sep 4, 2020
Angela Christine Fults Individual W-2 Managing EmployeeMedical Director Nov 1, 2021
Operational/Managerial ControlMedical Director Nov 1, 2021
St Luke's Healthcare Organization, Cedar Rapids, IA Corporation, Non-profit Operational/Managerial Control Jun 20, 2012
Tessa Wade Individual Corporate Officer Jan 1, 2020
Corporate Director Mar 27, 2019
Jillissa K Chvala Individual W-2 Managing EmployeeRHC Clinic Manager Apr 30, 2018
Operational/Managerial ControlRHC Clinic Manager Apr 30, 2018

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 2

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": "1623369600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623888000000",
    "number": "1639747108",
    "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": "728 47TH AVE",
            "city": "AMANA",
            "state": "IA",
            "postal_code": "522038031",
            "telephone_number": "319-225-8700",
            "fax_number": "319-225-8660"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARENGO MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARENGO MEMORIAL HOSPITAL",
        "enumeration_date": "2021-06-11",
        "last_updated": "2021-06-17",
        "certification_date": "2021-06-17",
        "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": "319-642-8160"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "COLONIES FAMILY MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Amana, IA

Sources for this page

Verify at the official NPI Registry.