Healthcare Provider Details

I. General information

NPI: 1205329596
Provider Name (Legal Business Name): MCCANN MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 E US HIGHWAY 34
GRAND ISLAND NE
68801-9734
US

IV. Provider business mailing address

2820 E US HIGHWAY 34
GRAND ISLAND NE
68801-9734
US

V. Phone/Fax

Practice location:
  • Phone: 308-227-2182
  • Fax:
Mailing address:
  • Phone: 308-210-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111775
License Number StateNE

VIII. Authorized Official

Name: CONNIE A MILLS
Title or Position: CONSULTANT
Credential:
Phone: 308-384-2282