Provider Demographics
NPI:1073590626
Name:BRODSTONE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BRODSTONE MEMORIAL HOSPITAL
Other - Org Name:SUPERIOR FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREG
Authorized Official - Middle Name:
Authorized Official - Last Name:VYZOUREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-879-3281
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:NE
Mailing Address - Zip Code:68978-0407
Mailing Address - Country:US
Mailing Address - Phone:402-879-4781
Mailing Address - Fax:402-879-3365
Practice Address - Street 1:525 E 11TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:NE
Practice Address - Zip Code:68978-1101
Practice Address - Country:US
Practice Address - Phone:402-879-4781
Practice Address - Fax:402-879-3365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRODSTONE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-26
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025177900Medicaid
NE=========13Medicaid
NE10025177900Medicaid
NE283478Medicare Oscar/Certification