Provider Demographics
NPI:1104859206
Name:CITY OF GENOA
Entity Type:Organization
Organization Name:CITY OF GENOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-993-4583
Mailing Address - Street 1:505 S PARK ST
Mailing Address - Street 2:PO BOX 310
Mailing Address - City:GENOA
Mailing Address - State:NE
Mailing Address - Zip Code:68640-3036
Mailing Address - Country:US
Mailing Address - Phone:402-993-2206
Mailing Address - Fax:402-993-2595
Practice Address - Street 1:505 S PARK ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:NE
Practice Address - Zip Code:68640-3036
Practice Address - Country:US
Practice Address - Phone:402-993-2206
Practice Address - Fax:402-993-2595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA RHMedicaid
NE10025924300 NRHMedicaid
NE273722254OtherCOMMERCIAL
NE273722254OtherBLUE CROSS BLUE SHIELD
NECS4410OtherRAILROAD MEDICARE
NENAOtherCHAMPUS
NECS4410OtherRAILROAD MEDICARE
NE098211Medicare PIN