Provider Demographics
NPI:1366659773
Name:JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-872-4100
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:308-872-4100
Mailing Address - Fax:308-872-4175
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:308-872-4100
Practice Address - Fax:308-872-4175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE07073OtherBLUE CROSS CRNA NUMBER
NE10025055300Medicaid
NE81010OtherBLUE CROSS DIABETIC ED NO
NEDB7316OtherRAILROAD MEDICARE NUMBER
NE10025055300Medicaid