Provider Demographics
NPI:1043384423
Name:CITY OF SUTHERLAND
Entity type:Organization
Organization Name:CITY OF SUTHERLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOERMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-446-2628
Mailing Address - Street 1:409 ASH ST
Mailing Address - Street 2:PO BOX 128
Mailing Address - City:SUTHERLAND
Mailing Address - State:IA
Mailing Address - Zip Code:51058-7663
Mailing Address - Country:US
Mailing Address - Phone:712-446-2243
Mailing Address - Fax:
Practice Address - Street 1:116 PINE ST
Practice Address - Street 2:
Practice Address - City:SUTHERLAND
Practice Address - State:IA
Practice Address - Zip Code:51058
Practice Address - Country:US
Practice Address - Phone:712-446-2242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2710600261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0068163Medicaid
IA06816OtherBLUE CROSS BLUE SHIELD
IA06816Medicare ID - Type Unspecified