Healthcare Provider Details

I. General information

NPI: 1245305655
Provider Name (Legal Business Name): JENNIE M MELHAM MEMORIAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MEMORIAL DR
BROKEN BOW NE
68822-1378
US

IV. Provider business mailing address

PO BOX 250
BROKEN BOW NE
68822-0250
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-2625
  • Fax: 308-872-6116
Mailing address:
  • Phone: 308-872-2625
  • Fax: 308-872-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier10025136500
Identifier TypeMEDICAID
Identifier StateNE
Identifier Issuer
# 2
Identifier00368
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS HOSPICE NUMBER

VIII. Authorized Official

Name: MR. TIMOTHY L SCHUCKMAN
Title or Position: VICE PRESIDENT-CFO
Credential:
Phone: 308-872-2625