1073605754 NPI number — MADONNA REHABILITATION HOSPITAL

Table of content: (NPI 1073605754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073605754 NPI number — MADONNA REHABILITATION HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADONNA REHABILITATION HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST JANE DE CHANTAL LONG TERM CARE SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073605754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-413-3000
Provider Business Mailing Address Fax Number:
402-413-4113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 S 52ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506-2030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-413-3000
Provider Business Practice Location Address Fax Number:
402-413-4113
Provider Enumeration Date:
09/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DONGILLI
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
402-413-3000

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  LTCH022 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: LTCH022 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0157020 . This is a "MEDICAID" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 00210 . This is a "BLUE CROSS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 5000016 . This is a "UNITEDHEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0605267 . This is a "MEDICAID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 112564800 . This is a "MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 100187780A . This is a "MEDICAID" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".