=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659476000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAINBRIDGE ORTHOPAEDIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 ALPHA ST
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-381-7200
-----------------------------------------------------
Fax | 308-382-3335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5500
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-381-7200
-----------------------------------------------------
Fax | 308-382-3335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | GORDON DELL BAINBRIDGE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 308-381-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------