Provider Demographics
NPI:1639218472
Name:PROVIDENCE MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL CENTER
Other - Org Name:PROVIDENCE HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-375-3800
Mailing Address - Street 1:1200 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1212
Mailing Address - Country:US
Mailing Address - Phone:402-375-3800
Mailing Address - Fax:402-375-7989
Practice Address - Street 1:1200 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1212
Practice Address - Country:US
Practice Address - Phone:402-375-3800
Practice Address - Fax:402-375-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEHOSPICE 29251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE281520Medicare Oscar/Certification