Provider Demographics
NPI:1598766735
Name:GRAND ISLAND CLINIC INC
Entity Type:Organization
Organization Name:GRAND ISLAND CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERBEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-382-1100
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-0550
Mailing Address - Country:US
Mailing Address - Phone:308-382-1100
Mailing Address - Fax:308-385-0796
Practice Address - Street 1:2444 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4327
Practice Address - Country:US
Practice Address - Phone:130-838-2110
Practice Address - Fax:308-385-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X, 208000000X
NE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECO4245OtherPALMETTO GBA
NE0282840001Medicare NSC
NECO4245OtherPALMETTO GBA