NPIMap

Organization Active NPI

Montgomery County Memorial Hospital

Doing business as Red Oak Medical Clinic

  • Rural Health Clinic/Center
  • Red Oak, IA
National Provider Identifier
1891405452
Registry record updated Dec 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MONTGOMERY COUNTY MEMORIAL HOSPITAL
Doing business as
Red Oak Medical Clinic
Practice address
1400 Senate Ave Ste 108 & 103
Red Oak, IA 51566-1271
Phone
(712) 623-7280
NPI assigned
Dec 5, 2022
Last updated
Dec 6, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
MONTGOMERY COUNTY MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 6, 2022

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

Authorized official

Name
Ronald G Kloewer
Title
Administrator/Ceo
Phone
(712) 623-7000

Specialties & licenses 1

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

Addresses

Primary practice location

1400 Senate Ave Ste 108 & 103
Red Oak, IA 51566-1271

Mailing address

PO Box 498
Red Oak, IA 51566-0498
Phone (712) 623-7000

Other names 1

  • RED OAK 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
O20221217000149 IA Part A Provider - Rural Health Clinic 9032015805 Practice locations: Red Oak, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1891405452. Details of each certification follow.

Rural health clinic certification: CCN 168664

Legal name
MONTGOMERY COUNTY MEMORIAL HOSPITAL
Doing business as
RED OAK MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 31, 2023
Last certification
Jan 31, 2023
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
1400 Senate Ave
Ste 108&103
Red Oak, IA 51566-1271
Related CCNs
161363

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

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
16D0935994Montgomery County Memorial Hospital Women's Health1400 Senate Ave, Suite 102, Red Oak, IA 51566Certificate of waiverFeb 18, 2028
16D2284428Red Oak Medical Clinic1400 Senate Ave, Red Oak, IA 51566ComplianceJan 16, 2028

National Provider Directory

National Provider Directory
Tax ID family
Montogomery Co Mem Hosp11 organizations share this tax ID, including this one
Part of
Montogomery Co Mem Hosp

Other organizations with this tax ID 10

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

Locations

1400 Senate Ave
Ste 103
Red Oak, IA 51566
Phone (712) 623-7240

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Daniela M Donoso Pena Individual W-2 Managing EmployeeMedical Director Dec 8, 2022
Operational/Managerial ControlMedical Director Dec 8, 2022
Jason R Poston Individual Corporate Director Jan 1, 2023
Shauna M Bozwell Individual W-2 Managing EmployeeOffice Manager Jan 17, 2022
Operational/Managerial ControlOffice Manager Jan 17, 2022
Ann M Carder Individual Corporate Director Jan 1, 2021
Jill C Bergstrom Individual Corporate Director Jan 1, 2019
James C Norris Individual Corporate Officer Jan 1, 2023
Corporate Director Jan 1, 2021
Michael C Oneal Individual W-2 Managing EmployeeCoo Oct 31, 2021
Operational/Managerial ControlCoo Oct 31, 2021
Roger J Ehmke Individual Corporate Officer Jan 1, 2021
Corporate Director Jan 1, 1999
Kevin T Cabbage Individual Corporate Officer Jan 1, 2016
Corporate Director Jan 1, 2007
Lorin E Petersen Individual Corporate Officer Jan 1, 2019
Corporate Director Mar 3, 2000
Ronald G Kloewer Individual Corporate OfficerAdministrator/Ceo Mar 15, 2021
W-2 Managing EmployeeAdministrator/Ceo Mar 15, 2021
Operational/Managerial ControlAdministrator/Ceo Mar 15, 2021
Jamie L Hossle Individual W-2 Managing EmployeeDirector Revenue Cycle Jun 27, 2022
Operational/Managerial ControlDirector Revenue Cycle Jun 27, 2022
Bryant J Blay Individual Corporate OfficerCfo Dec 31, 2022
W-2 Managing EmployeeCfo Apr 18, 2016
Operational/Managerial ControlCfo Apr 18, 2016

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 1

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": "1670198400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670284800000",
    "number": "1891405452",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 498",
            "city": "RED OAK",
            "state": "IA",
            "postal_code": "515660498",
            "telephone_number": "712-623-7000",
            "fax_number": "712-623-7224"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 SENATE AVE STE 108 & 103",
            "city": "RED OAK",
            "state": "IA",
            "postal_code": "515661271",
            "telephone_number": "712-623-7280"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MONTGOMERY COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MONTGOMERY COUNTY MEMORIAL HOSPITAL",
        "enumeration_date": "2022-12-05",
        "last_updated": "2022-12-06",
        "certification_date": "2022-12-06",
        "status": "A",
        "authorized_official_last_name": "KLOEWER",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "ADMINISTRATOR/CEO",
        "authorized_official_telephone_number": "712-623-7000"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "RED OAK MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Red Oak, IA

Sources for this page

Verify at the official NPI Registry.