Provider Demographics
NPI:1033126107
Name:CCH PEDIATRIC CLINIC PC
Entity Type:Organization
Organization Name:CCH PEDIATRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO FAAP
Authorized Official - Phone:402-564-7200
Mailing Address - Street 1:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68602
Mailing Address - Country:US
Mailing Address - Phone:402-564-7200
Mailing Address - Fax:402-564-7210
Practice Address - Street 1:4508 38TH ST
Practice Address - Street 2:STE 165
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601
Practice Address - Country:US
Practice Address - Phone:402-564-7200
Practice Address - Fax:402-564-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025279800Medicaid
NE10025279800Medicaid