MEDICARE: CITY OF GENOA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1386157071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF GENOA

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:
City	:	GENOA
State	:	NE
Zip	:	68640-0310
Country	:	US
Telephone Number	:	402-993-2283
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 BROADWAY ST
Second Line	:
City	:	FULLERTON
State	:	NE
Zip	:	68638-3152
Country	:	US
Telephone Number	:	402-993-2283
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AMANDA ROEBUCK
Credential	:
Telephone Number	:	402-993-4583

Provider Enumeration Date	:	11/16/2017
Last Update Date	:	01/23/2020

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Directions to “CITY OF GENOA ” Practice Location

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