1285862359 NPI number — MINNECHADUZA MEDICAL CLINIC P.C.

Table of content: (NPI 1285862359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285862359 NPI number — MINNECHADUZA MEDICAL CLINIC P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNECHADUZA MEDICAL CLINIC P.C.
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:
MINNECHADUZA MEDICINE
Provider Other Organization Name Type Code:
5
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:
1285862359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 E 1ST ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
VALENTINE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69201-1802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-376-1368
Provider Business Mailing Address Fax Number:
866-614-6108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 E 1ST ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
VALENTINE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69201-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-376-1368
Provider Business Practice Location Address Fax Number:
866-614-6108
Provider Enumeration Date:
06/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RYSCHON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
402-389-2121

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  20604 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 4298 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 43417 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 536 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00866 . This is a "BCBS NEBRASKA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 7714810 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025277700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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