NPIMap

Organization Active NPI

Marengo Memorial Hospital

Doing business as Victor Family Medical Clinic

  • Rural Health Clinic/Center
  • Victor, IA
National Provider Identifier
1679246722
Registry record updated Jul 28, 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
Victor Family Medical Clinic
Practice address
709 2ND St
Victor, IA 52347-7709
Phone
(319) 647-7511
NPI assigned
Jul 26, 2021
Last updated
Jul 28, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
MARENGO MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 28, 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) 642-5543

Specialties & licenses 1

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

Addresses

Primary practice location

709 2ND St
Victor, IA 52347-7709

Mailing address

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

Other names 1

  • VICTOR 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
O20210809002014 IA Part A Provider - Rural Health Clinic 0749199446 Practice locations: Victor, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679246722. Details of each certification follow.

Rural health clinic certification: CCN 168510

Legal name
MARENGO MEMORIAL HOSPITAL
Doing business as
VICTOR FAMILY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 17, 2006
Last certification
May 24, 2023
Ownership / control type
Non-profit – church related
Most recent change of ownership
Sep 1, 2021 (1 total)
Organization structure
OtherNon-profit
Enrollment address
709 2ND St
Victor, IA 52347-7709
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).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D0997633Victor Family Medical Clinic709 Second Street, Victor, IA 52347Certificate of waiverJan 27, 2027

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.

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 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
Benjamin M Miller Individual W-2 Managing EmployeeMedical Director Sep 1, 2021
Operational/Managerial ControlMedical Director Sep 1, 2021
Mary Warwick Individual W-2 Managing EmployeeDirector of Administrative Services Jan 1, 2010
Wendy Jordan Individual Corporate OfficerDirector of Finance Sep 4, 2020
W-2 Managing EmployeeDirector of Finance Sep 4, 2020
Operational/Managerial ControlDirector of Finance Sep 4, 2020
St Luke's Healthcare Organization, Cedar Rapids, IA Corporation, Non-profit Operational/Managerial Control Jun 20, 2012
Beau Jack Individual Corporate Director Dec 4, 2023
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

Change-of-ownership history 1

DateEventCounterparty
Sep 1, 2021 Change of OwnershipThis provider was the buyer Victor Health CenterCCN 168510, IA, NPI 1720154263

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

NPI Registry JSON

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

{
    "created_epoch": "1627257600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1627430400000",
    "number": "1679246722",
    "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": "709 2ND ST",
            "city": "VICTOR",
            "state": "IA",
            "postal_code": "523477709",
            "telephone_number": "319-647-7511"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARENGO MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARENGO MEMORIAL HOSPITAL",
        "enumeration_date": "2021-07-26",
        "last_updated": "2021-07-28",
        "certification_date": "2021-07-28",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "VICTOR FAMILY MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Victor, IA

Sources for this page

Verify at the official NPI Registry.