Montgomery County Memorial Hospital
Organization Active NPI Rural Health Clinic/Center · Malvern, IA
NPI 1639768401 · NPPES record last updated Dec 6, 2022
Key facts
- NPI
- 1639768401
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MONTGOMERY COUNTY MEMORIAL HOSPITAL
- Practice address
- 908 Main St
Malvern, IA 51551-8147 - Phone
- (712) 624-6010
- NPI assigned
- Jan 15, 2021
- Organization subpart
- Yes
- Parent organization (as reported)
- MONTGOMERY COUNTY MEMORIAL HOSPITAL
Authorized official
- Name
- Ronald G Kloewer
- Title
- Administrator/Ceo
- Phone
- (712) 623-7000
Owners & managing parties with NPI records 1
-
Thomas M Baer, M.D.
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 10
Related certifications (CCN) 1
Practitioners 45
-
Thomas M Baer, M.D.
-
Claudia M. Balta, P.A.
-
William Butz, M.D.
-
Brian E. Couse, MD
-
Warren C Hayes, M.D.
-
Scott D. Hoffman, D.O.
-
Abby Johnson, FNP-C
-
Kelsey Brooke Johnson, ARNP
-
Lizabeth Jean Johnson, APRN
-
Eva-Anne Marie Kentner, ARNP
-
Angela Marie Kerchner, M.D.
-
Jason Troy Lihs, CRNA
-
Emily L Maass, APRN
-
Sumit Mukherjee, M.D.
-
Christopher Olsen, ARNP
-
David Michael Owen, A.R.N.P.
-
Jeremy P Pepin, M.D.
-
Ara J Robinson, D.O.
-
Colleen M Ross, NP
-
Brianna Jean Schaffer, ARNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 16D2167384 | Malvern Medical Clinic | Certificate of waiver | Jun 5, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IA
Rural health clinic certification: CCN 168653
- Legal name
- MONTGOMERY COUNTY MEMORIAL HOSPITAL
- Doing business as
- MALVERN MEDICAL CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 26, 2021
- Last certification
- Mar 26, 2021
- Ownership / control type
- Non-profit – church related
- Organization structure
- Other · Non-profit
- Enrollment address
- 908 Main St
Malvern, IA 51551-8147 - Related CCNs
- 161363
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Thomas M Baer |
W-2 Managing Employee |
Mar 26, 2021 | |
| Operational/Managerial Control |
Mar 26, 2021 | ||
| Jason R Poston |
Corporate Officer | Jan 1, 2026 | |
| Corporate Director | Jan 1, 2023 | ||
| Shauna M Bozwell |
W-2 Managing Employee |
Jan 17, 2022 | |
| Operational/Managerial Control |
Jan 17, 2022 | ||
| Ann M Carder |
Corporate Officer | Jan 1, 2023 | |
| Corporate Director | Jan 1, 2021 | ||
| Jill C Bergstrom |
Corporate Officer | Jan 1, 2023 | |
| Corporate Director | Jan 1, 2019 | ||
| James C Norris |
Corporate Officer | Jan 1, 2023 | |
| Corporate Director | Jan 1, 2021 | ||
| Michael C Oneal |
Corporate Officer |
Mar 16, 2026 | |
| W-2 Managing Employee |
Oct 31, 2021 | ||
| Operational/Managerial Control |
Oct 31, 2021 | ||
| Jeffery L Vanderhoof |
Corporate Director | Jan 1, 2025 | |
| Kevin T Cabbage |
Corporate Director | Jan 1, 2007 | |
| Christopher K Gilbert |
Corporate Director | Jan 29, 2025 | |
| Jamie L Hossle |
W-2 Managing Employee |
Jun 27, 2022 | |
| Operational/Managerial Control |
Jun 27, 2022 | ||
| Bryant J Blay |
Corporate Officer |
Dec 31, 2022 | |
| W-2 Managing Employee |
Apr 18, 2016 | ||
| Operational/Managerial Control |
Apr 18, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210120001334 | IA | Part a Provider - Rural Health Clinic | 9032015805 | Practice locations: Malvern, IA |
National Provider Directory
- Tax ID family
- Montgomery County Memorial Hospital
- Part of
- Montgomery County Memorial Hospital
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
908 Main St
Malvern, IA 51551-8147
Mailing address
PO Box 498
Red Oak, IA 51566-0498
Phone (712) 623-7000
Other names
- Malvern Medical Clinic
Other providers in Malvern, IA
- Lancial Chiropractic
- Natalie Lancial
- Malvern C.S.D.
- Malvern Volunteer Rescue, Inc.
- Manor of Malvern Inc.
- Morse Healthcare Services Inc.
- Caroline Obermiller
- Physicians Clinic, Inc.
- Megan Jo Platt
- Kaleb Richter
All providers in Malvern, IA · Rural Health Clinic/Center in Iowa
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 6, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.