Provider Demographics
NPI:1265507677
Name:JENNIE M MELHAM MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:JENNIE M MELHAM MEMORIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-872-2625
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-0250
Mailing Address - Country:US
Mailing Address - Phone:308-872-2625
Mailing Address - Fax:308-872-6116
Practice Address - Street 1:145 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-1378
Practice Address - Country:US
Practice Address - Phone:308-872-2625
Practice Address - Fax:308-872-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
008977OtherBLUE CROSS DME NUMBER
NE=========01Medicaid