Provider Demographics
NPI:1679508022
Name:MARIAN HEALTH CENTER -SMHC
Entity type:Organization
Organization Name:MARIAN HEALTH CENTER -SMHC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLANTYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-428-3086
Mailing Address - Street 1:801 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1326
Mailing Address - Country:US
Mailing Address - Phone:712-279-2010
Mailing Address - Fax:712-279-5681
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:712-279-5681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA970112H273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA005068000Medicaid
IA6S153OtherWELLMARK BLX
SD0235060Medicaid
IA005068000Medicaid