1104859206 NPI number — CITY OF GENOA

Table of content: (NPI 1104859206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104859206 NPI number — CITY OF GENOA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF GENOA
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:
Provider Other Organization Name Type Code:
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:
1104859206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 S PARK ST
Provider Second Line Business Mailing Address:
PO BOX 310
Provider Business Mailing Address City Name:
GENOA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68640-3036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-993-2206
Provider Business Mailing Address Fax Number:
402-993-2595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 S PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENOA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68640-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-993-2206
Provider Business Practice Location Address Fax Number:
402-993-2595
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROEBUCK
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
402-993-4583

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NA RH , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025924300 NRH , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273722254 . This is a "COMMERCIAL" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 273722254 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: CS4410 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: NA . This is a "CHAMPUS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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