Provider Demographics
NPI:1619948551
Name:FAIRBURY CLINIC, P.C.
Entity Type:Organization
Organization Name:FAIRBURY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLENBERNDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-729-3361
Mailing Address - Street 1:825 22ND ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-1299
Mailing Address - Country:US
Mailing Address - Phone:402-729-3361
Mailing Address - Fax:
Practice Address - Street 1:825 22ND ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-1299
Practice Address - Country:US
Practice Address - Phone:402-729-3361
Practice Address - Fax:402-729-4010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100300280AMedicaid
KS100300280BMedicaid
NE=========12Medicaid
NE=========21Medicaid
NE=========12Medicaid
NE283826Medicare Oscar/Certification
KS100300280AMedicaid