Provider Demographics
NPI:1285862359
Name:MINNECHADUZA MEDICAL CLINIC P.C.
Entity Type:Organization
Organization Name:MINNECHADUZA MEDICAL CLINIC P.C.
Other - Org Name:MINNECHADUZA MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RYSCHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-389-2121
Mailing Address - Street 1:148 E 1ST ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-1802
Mailing Address - Country:US
Mailing Address - Phone:402-376-1368
Mailing Address - Fax:866-614-6108
Practice Address - Street 1:148 E 1ST ST
Practice Address - Street 2:SUITE 400
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1802
Practice Address - Country:US
Practice Address - Phone:402-376-1368
Practice Address - Fax:866-614-6108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20604208000000X
SD4298208000000X
CO43417208000000X
CO536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00866OtherBCBS NEBRASKA
SD7714810Medicaid
NE10025277700Medicaid