Provider Demographics
NPI:1417167370
Name:CHADRON MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:CHADRON MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LANDRETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-432-4441
Mailing Address - Street 1:825 CENTENNIAL DR
Mailing Address - Street 2:PO BOX 431
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-9400
Mailing Address - Country:US
Mailing Address - Phone:308-432-4441
Mailing Address - Fax:308-432-4446
Practice Address - Street 1:825 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-9400
Practice Address - Country:US
Practice Address - Phone:308-432-4441
Practice Address - Fax:308-432-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01981OtherBLUE SHIELD
NE01981OtherBLUE SHIELD
NE=========12Medicaid
NE=========12Medicaid