Healthcare Provider Details

I. General information

NPI: 1073590626
Provider Name (Legal Business Name): BRODSTONE MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 11TH ST
SUPERIOR NE
68978-1101
US

IV. Provider business mailing address

PO BOX 407
SUPERIOR NE
68978-0407
US

V. Phone/Fax

Practice location:
  • Phone: 402-879-4781
  • Fax: 402-879-3365
Mailing address:
  • Phone: 402-879-4781
  • Fax: 402-879-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TREG VYZOUREK
Title or Position: CEO
Credential:
Phone: 402-879-3281