1639123185 NPI number — FAMILY PRACTICE OF GRAND ISLAND P C

Table of content: (NPI 1639123185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639123185 NPI number — FAMILY PRACTICE OF GRAND ISLAND P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRACTICE OF GRAND ISLAND 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:
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:
1639123185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9802
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68802-9802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-381-0162
Provider Business Mailing Address Fax Number:
308-389-4445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3563 PRAIRIEVIEW ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-4442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-381-0162
Provider Business Practice Location Address Fax Number:
308-389-4445
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUSEN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
308-381-0162

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 28D0455757 . This is a "CLIA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: ========= , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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