1093880072 NPI number — JENNIE M MELHAM MEMORIAL MEDICAL CENTER

Table of content: (NPI 1093880072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093880072 NPI number — JENNIE M MELHAM MEMORIAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNIE M MELHAM MEMORIAL MEDICAL CENTER
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:
6
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:
1093880072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN BOW
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68822-0250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-872-2625
Provider Business Mailing Address Fax Number:
308-872-6116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN BOW
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68822-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-872-2625
Provider Business Practice Location Address Fax Number:
308-872-6116
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHUCKMAN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VICE PRESIDENT-CFO
Authorized Official Telephone Number:
307-872-2625

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  LTCH004 , 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)





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