1417167370 NPI number — CHADRON MEDICAL CLINIC PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417167370 NPI number — CHADRON MEDICAL CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHADRON MEDICAL CLINIC PC
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:
1417167370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 CENTENNIAL DR
Provider Second Line Business Mailing Address:
PO BOX 431
Provider Business Mailing Address City Name:
CHADRON
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69337-9400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-432-4441
Provider Business Mailing Address Fax Number:
308-432-4446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 CENTENNIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHADRON
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69337-9400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-432-4441
Provider Business Practice Location Address Fax Number:
308-432-4446
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LANDRETH
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
308-432-4441

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , 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: 01981 . This is a "BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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