Marengo Memorial Hospital
Organization Active NPI Rural Health Clinic/Center · Victor, IA
NPI 1679246722 · NPPES record last updated Jul 28, 2021
Key facts
- NPI
- 1679246722
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MARENGO MEMORIAL HOSPITAL
- Practice address
- 709 2ND St
Victor, IA 52347-7709 - Phone
- (319) 647-7511
- NPI assigned
- Jul 26, 2021
- Organization subpart
- Yes
- Parent organization (as reported)
- MARENGO MEMORIAL HOSPITAL
Authorized official
- Name
- Barry G Goettsch
- Title
- Ceo
- Phone
- (319) 642-5543
Owners & managing parties with NPI records 1
-
Benjamin Miller, D.O.
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 8
Related certifications (CCN) 1
Change of ownership 1
Facilities with the same owner 19
Practitioners 37
-
Julie Rae Baburek, ARNP
-
Randy Dean Cornelius, CRNA
-
Julia Clara Dennis, CRNA
-
Madelynn Rose Dickinson, ARNP
-
Ross G Doehrmann, DO
-
Taylor Marie Felker, DNP, ARNP, FNP-BC
-
Angela Fults, DO
-
Chirantan Ghosh, MD
-
Kyle M Hawkins, PA-C
-
Brian J Heineman, DO
-
Stephanie Lynn Huyck, DNP, ARNP, FNP-C
-
Madelyn Nicole Kussmann, PA-C
-
Daniel Kwai Lee, MD
-
Sara Magill, DNP
-
Michelle M Malloy, ARNP
-
Mindy Teann Martin, ARNP
-
Benjamin Miller, D.O.
-
Robert Rogers, ARNP
-
Leslie Schier, MD
-
Mark Allen Siebrecht, D.P.M.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 16D0997633 | Victor Family Medical Clinic | Certificate of waiver | Jan 27, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IA
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
- Other · Non-profit
- Enrollment address
- 709 2ND St
Victor, IA 52347-7709 - Related CCNs
- 161317
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Barry Gene Goettsch |
Corporate Officer |
May 28, 2014 | |
| W-2 Managing Employee |
Jul 6, 2011 | ||
| Operational/Managerial Control |
Jul 6, 2011 | ||
| Jessica Hlubek |
Corporate Officer | Jan 23, 2019 | |
| Corporate Director | Mar 31, 2017 | ||
| Trenton a Forrest |
Corporate Director | Jun 28, 2023 | |
| Jeff Meier |
Corporate Director | Mar 23, 2022 | |
| Emily Cahoy |
W-2 Managing Employee | Aug 8, 2022 | |
| Benjamin M Miller |
W-2 Managing Employee |
Sep 1, 2021 | |
| Operational/Managerial Control |
Sep 1, 2021 | ||
| Mary Warwick |
W-2 Managing Employee |
Jan 1, 2010 | |
| Wendy Jordan |
Corporate Officer |
Sep 4, 2020 | |
| W-2 Managing Employee |
Sep 4, 2020 | ||
| Operational/Managerial Control |
Sep 4, 2020 | ||
| St Luke'S Healthcare |
Operational/Managerial Control | Jun 20, 2012 | |
| Beau Jack |
Corporate Director | Dec 4, 2023 | |
| Tessa Wade |
Corporate Officer | Jan 1, 2020 | |
| Corporate Director | Mar 27, 2019 | ||
| Jillissa K Chvala |
W-2 Managing Employee |
Apr 30, 2018 | |
| Operational/Managerial Control |
Apr 30, 2018 |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| Sep 1, 2021 | Change of Ownership |
Victor Health Center |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210809002014 | IA | Part a Provider - Rural Health Clinic | 0749199446 | Practice locations: Victor, IA |
National Provider Directory
- Tax ID family
- Marengo Mem Hosp ER Phy
- Part of
- Marengo Mem Hosp ER Phy
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
- VICTOR FAMILY MEDICAL CLINIC
Other providers in Victor, IA
- Grinnell Regional Medical Center
- H-L-V CSD
- HLV Community School District
- Hy-Vee Inc
- MCLD Corporation
- MCLD Corporation
- Reflections Health and Wellness LLC
- Lacinda Root
- Ashley Marie Siefkas
All providers in Victor, 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 Jul 28, 2021. 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.