Healthcare Provider Details

I. General information

NPI: 1982779641
Provider Name (Legal Business Name): JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
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: 308-872-4100
  • Fax: 308-872-4175
Mailing address:
  • Phone: 308-872-4100
  • Fax: 308-872-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number100004
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number100004
License Number StateNE

VIII. Authorized Official

Name: KYLE D KELLUM
Title or Position: CEO AND PRESIDENT
Credential:
Phone: 308-872-4100