MEDICARE: CITY OF GENOA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09253	OTHER	NE	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1487621561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF GENOA

Provider Business Mailing Address
First Line	:	PO BOX 190
Second Line	:
City	:	GENOA
State	:	NE
Zip	:	68640-0190
Country	:	US
Telephone Number	:	402-572-4019
Fax Number	:	402-965-8594

Provider Business Practice Location Address
First Line	:	516 WILLARD AVE
Second Line	:
City	:	GENOA
State	:	NE
Zip	:	68640-3039
Country	:	US
Telephone Number	:	402-572-4019
Fax Number	:	402-965-8594

Authorized Official
Title or Position	:	SECRETARY
Name	:	VIRGINIA L JOHNSON
Credential	:
Telephone Number	:	402-572-4019

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	08/22/2020

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Directions to “CITY OF GENOA ” Practice Location

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