Provider Demographics
NPI:1477953305
Name:GOTHENBURG MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GOTHENBURG MEMORIAL HOSPITAL
Other - Org Name:GOTHENBURG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-537-3661
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-0469
Mailing Address - Country:US
Mailing Address - Phone:308-537-3661
Mailing Address - Fax:308-537-3074
Practice Address - Street 1:918 20TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-4066
Practice Address - Fax:308-537-4038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOTHENBURG MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-28
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28Z313Medicare PIN
NE281313Medicare PIN